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Traumatic brain injury

Dr Mahmoud Ibrahim Mekhaimar and Dr Henry Knipe ◉ ◈ et al.

Traumatic brain injuries (TBI) are common and come with a large cost to both society and
the individual. The diagnosis of traumatic brain injury is a clinical decision, however, imaging,
particularly CT, plays a key role in diagnostic work-up, classification, prognostication and
follow-up. 

They can be broadly divided into closed and penetrating head injuries 4:

closed head injury

vastly more common
blunt trauma: motor vehicle collision, assault, sport, industrial/workplace
accidents, etc
blast injuries
non-accidental injury in children
penetrating head injury
high-velocity penetrating brain injury e.g. gunshot injuries
low-velocity penetrating brain injury e.g. stabbing

The remainder of this article focuses on closed head injury. 

On this page:
Article:

Epidemiology
Clinical presentation
Pathology
Imaging indications:
Radiographic features
Treatment and prognosis
References
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Images:

Cases and figures

Epidemiology

Traumatic brain injuries are more common in young patients, and men account for the
majority (75%) of cases 4. Although sport is a common cause of relatively mild repeated head
injury potentially eventually leading to chronic traumatic encephalopathy, more severe
injuries are most often due to motor vehicle accidents and assault. 

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Clinical presentation

Patients typically present with a combination of reduced Glasgow Coma Scale (GCS),
nausea/vomiting and/or amnesia 3. The severity of the injury can be assessed with GCS 4:

mild TBI: GCS 14-15

moderate TBI: GCS 9-13
severe TBI: GCS 3-8

This scale has limitations as there are other causes for reduced GCS in trauma (alcohol, drugs,
seizure, etc). 

The terms concussion refers to a clinical diagnosis which has overlap with the mild spectrum
of TBI, and usually is used in reference to a transient brain injury 8. 

The potential long term sequelae of repetitive traumatic brain injury is a current area of
research. Chronic traumatic encephalopathy describes neurodegeneration associated with
repetitive head injuries, and characteristed microscopically by accumulation of
hyperphosphoyrlated tau in neurons. 

Pathology

In the acute setting patients can present with primary brain damage 4: 
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 traumatic subarachnoid hemorrhage (tSAH)
subdural hematoma (SDH)
extradural hematoma (EDH)
intraventricular hemorrhage
cerebral hemorrhagic contusion
intermediary injury
diffuse axonal injury (DAI)

Secondary brain damage can also occur and manifests as 4:

generalized cerebral edema

hypoxic-ischemic brain injury
ischemic stroke from traumatic arterial dissection
"big black brain"

Long-term sequelae of head trauma include:

encephalomalacia/gliosis
chronic subdural hematomas / CSF hygromas
chronic traumatic encephalopathy
depression, anxiety and alcohol abuse 5
increased risk of schizophrenia, bipolar disorder and organic mental disorders 6

Complications

Severe mass effect can result in:

midline shift: associated with worse prognosis

cerebral herniation: often requires urgent treatment
hydrocephalus: can also be a chronic non-mass effect related complication

Associations

Other traumatic injuries are common:

cervical spine injury: patients with GCS <8 are most at risk 7
skull fracture
facial fracture
pneumocephalus
extracranial injuries in 35% 4

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Imaging indications:

The decision to perform imaging in the setting of head trauma will depend on multiple factors,
including local department guidelines and access to imaging. Various clinical tools exist which
help to screen for patients who require acute neuro-imaging, including: the Canadian Head CT
Rule, the National Emergency X-Radiography Utilization study II (NEXUS-II) criteria, and the
American College of Radiology Appropriateness Criteria for head trauma. 

Potential indications for performing CT in the acute setting for patients with concussion (to
exclude more serious forms of TBI such as intra-cranial hemorrhage) may include the
following: loss of consciousness, post-traumatic amnesia, persistent altered mental status, focal
neurology, signs of skull fractures or evidence of clinical deterioration 8.  

Radiographic features

skull fracture
may be associated with tearing of the underlying meninges and extra-axial
hemorrhage
anterior cranial fossa fractures are often associated with CSF leak
fractures traversing the dural venous sinus or jugular bulb are often associated with
injuries to the venous structures (e.g. compression from an extra-axial hematoma
and/or thrombosis)
extradural hematoma
subdural hematoma
mixed-attenuation SDH are not necessarily acute on chronic; other causes of
hypoattenuating portions of subdural hematomas include hyperacute hemorrhage
and unclotted chronic blood products (particularly in patients with coagulopathy) 8.
subdural hygroma
caused by tearing of the arachnoid membrane with CSF accumulation in the
subdural space.
can occur in the first day of trauma, but mean time to appearance is 9 days after
injury 8.
traumatic SAH
usually small volume sulcal SAH occurring at the site of impact (coup) or opposite
the site of impact (contrecoup).
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 midline traumatic SAH in the inter-hemispheric fissure or perimesencephalic
cisterns may be a marker of diffuse axonal injury. SAH in the interpeduncular
cisterns may indicate brainstem injury.
isolated SAH in the basilar cisterns may require investigation for underlying
vascular aneurysm.
intraventricular hemorrhage
in the setting of trauma, this may occur from a ruptured subependymal vein,
extension from intra-parenchymal hemorrhage or retrograde distribution from the
subarachnoid space.
brain contusion
commonly at the inferior frontal lobes and anterior-inferior temporal lobes due to
the ridged morphology of the inner table.
axonal injury
results from axonal stretch or shear stress, usually affecting organized white matter
tracts (e.g. corpus callosum, internal capsule, dorsal midbrain or pons) or the grey-
white matter interface (particularly in the frontal lobes).
more sensitively detected on MRI. May be associated with restricted diffusion.
Imaging often underestimate the full extent of axonal injury present
can be hemorrhagic or non-hemorrhagic.
graded in order of increasing severity;
grade 1: involves subcortical white matter
grade 2: involves corpus callosum
grade 3: involves the brainstem
thalamic lesions are not included in grading system but are associated with a
poor prognosis when present 8.
diffuse cerebral edema
thought to be related to dysfunctional cerebral autoregulation or blood-brain
barrier disruption; both vasogenic and cytotoxic edema may occur.
vascular injuries
arterial dissection (particularly in the setting of skull base fractures)
pseudoaneurysm (most commonly involving the vertebral artery or anterior
cerebral artery)
extrvasation
vascular occlusion
traumatic carotid-cavernous fistula
traumatic dural arteriovenous fistula
venous thrombosis (particularly when a fracture traverses the dural venous sinus)
second brain injuries and herniation
subfalcine herniation, transtentorial herniation (unilateral or bilateral, downward
or ascending), cerebellar tonsillar herniation
various herniation patterns can also result in ventricular entrapment

CT

CT is the workhorse of imaging in TBI, especially in the acute setting, and is able to identify the
majority of injuries at the time of presentation. It is common for multiple injuries to be present
simultaneously, such as the combination of cerebral contusions and traumatic subarachnoid,
subdural and extradural hemorrhage as well as skull fractures and facial fractures – these are
discussed separately. Benefits of CT in the acute setting over MRI include increased sensitive
for detection of fracture, vascular injury, CSF leak, and not needing to assess for MRI safety
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(particular in the setting of penetrating injury). 
CT can also be used to formally classify the degree of injury using a formal scale (e.g. Marshall
classification or Rotterdam CT score).

MRI

MRI has a supplementary role, especially in the evaluation of patients whose clinical condition
do not match the CT findings (this can often occur in DAI) 1,2. MRI has increased sensitivity in
detecting blood products (SAH, EDH, SDH and hemorrhagic contusions), non hemorrhagic
cortical contusions, brain-stem injuries and axonal injuries 8. There is evidence to support the
use of MRI in the setting of normal CT if there are persistent unexplained neurological findings
and clinically TBI is suspected. MRI is the preferred imaging modality in the setting of
subacute or chronic TBI with neurologic symptoms due to its higher sensitivity 8.  Please see
the relevant articles for imaging findings. 

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Treatment and prognosis

Large hematomas with significant mass effect require urgent neurosurgical evacuation.
Hydrocephalus can develop and urgent ventricular drainage may be required. Intracranial
pressure (ICP) monitor insertion is a common procedure used to help in the assessment of
severe TBI. 

Ongoing follow-up with CT is often required. In patients with diffuse injuries ~15% will
develop new lesions, and ~35% (range 25-45%) of cerebral contusions will increase in size with
progression thought to typically occur 6-9 hours after injury 4. 

Quiz questions

References
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Clinical tool developed to identify children with TBI at
low-risk for ICU-level care
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Article information
rID: 46289
Systems: Central Nervous System, Trauma
Synonyms or Alternate Spellings:

Closed head injury

Traumatic brain injuries
TBI
Penetrating head injury
Penetrating brain injury (PBI)
Closed brain injury (CBI)

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Cases and figures

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Case 1Case 1
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Case 2Case 2
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Case 3: gun shot injuryCase 3: gun shot injury

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Case 4: with ICP monitorCase 4: with ICP monitor
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Case 5: diffuse axonal injuryCase 5: diffuse axonal injury

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Case 6: penetrating head injury (stabbing)Case 6: penetrating head injury (stabbing)

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Case 7: Chronic penetrating traumatic brain injury - intracranial bulletCase 7: Chronic
penetrating traumatic brain injury - intracranial bullet
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