HEAD INJURY

Head injury introduction

Head injuries are one of the most common causes of death and disability in the United States. Every
year, almost a quarter million people are hospitalized because of traumatic injuries to the brain, and
50,000 people die. As well, 80-90,000 people sustain long-term or lifelong disabilities because of a
brain injury each year. Children are not excluded, with more than 2,500 deaths and almost a half
million emergency department visits per year for head injuries.

Blows to the head most often cause brain injury, it is important to remember that the face and jaw
are located in the front of the head. Brain injury may also be associated with injuries to these
structures. It is also important to note that a head injury does not always mean that there is also a
brain injury.

The brain is a rather soft, pliable material almost jelly-like in feel, and is surrounded by a thin layer of
cerebrospinal fluid (CSF). The brain is surrounded by thin layers of tissue called the meninges; 1)
the pia mater, 2) the arachnoid mater, and 3) the dura mater. The CSF is present in the space
beneath the arachnoid layer called the subarachnoid space.

The dura mater is very thick and has septae, or partitions, that help support the brain in the skull.
The septae attach to the inner lining of the bones of the skull. The dura mater also helps support the
large veins that return blood from the brain to the heart.

The spaces between the meninges are usually very small but they can fill with blood when trauma
occurs, and this build-up of blood can potentially press into the brain tissue and cause damage.

The skull protects the brain from trauma but it does not absorb any of the impact from a blow. Direct
blows may cause fractures of the skull; there can be a contusion or bruising and bleeding to the
brain tissue directly beneath the injury site. However, the brain can bounce around inside the skull if
it is subject to significant force and because of this, the brain injury may not necessarily be located
directly below the trauma site. A contre-coup injury describes the situation in which the initial blow
causes the brain to bounce and is damaged by hitting the skull directly opposite the trauma site.
Acceleration/deceleration and rotation are the common types of forces that can cause injuries away
from the area of the skull that received the trauma.
Picture of the brain and potentially brain injury areas

Head injuries due to bleeding are often classified by the location of the blood within the skull.

 Epidural hematoma: With an epidural hematoma, the bleeding is located between the dura
mater and the skull. This is often present along the side of the head where the middle
meningeal artery runs in a groove along the temporal bone. This bone is relatively thin and
offers less protection than other parts of the skull. As the bleeding continues, the hematoma or
clot expands. There is little space in the skull for the hematoma to grow and as it expands, the
adjacent brain tissue is compressed. As the pressure increases, the whole brain begins to shift
and becomes compressed against the bones of the skull. The pressure tends to build quickly
because the septae that attach the dura to the skull bones create small spaces that trap blood.
Symptoms of head injury and decreased level of consciousness occur as the pressure
increases.
 Subdural hematoma: A subdural hematoma is located beneath the dura mater
(sub=below), between it and the arachnoid mater. Blood in this space is able to dissipate into a
larger space because there are no septae limiting the blood flow. However, after a period of
time, the amount of bleeding may cause increased pressure and cause symptoms similar to
those seen with an epidural hematoma.

 Subarachnoid bleed: Subarachnoid bleeding occurs in the space beneath the arachnoid
layer where the CSF is located. Often there is intense headache and vomiting with
subarachnoid bleeding. Because this space connects with the spinal canal, pressure build-up
tends not to occur. However, this injury often occurs in combination with the other types of
bleeding in the brain, and the symptoms can be compounded.

 Intracerebral bleed: Intracerebral bleeding occurs within the brain tissue itself. Sometimes
the amount of bleeding is small, but like bruising in any other part of the body, swelling or
edema may occur over a period of time, causing a progressive decrease in the level of
consciousness and other symptoms of head injury.

 Sheer injury: Sometimes, the damage is due to sheer injury, where there is no obvious
bleeding in the brain, but instead the nerve fibers within the brain are stretched or torn. Another
term for this type of injury is diffuse axonal injury.

 Edema: All injuries to the brain may also cause swelling or edema, no different than the
swelling that surrounds a bruise on an arm or leg. However, because the bones of the skull
cannot stretch to accommodate the extra volume caused by swelling, the pressure increases
inside the skull and causes the brain to compress against the skull.

 Scull fracture: The bones of the skull are classified as flat bones, meaning that they do not
have an inside marrow. It takes a significant amount of force to break the skull, and the skull
does not absorb any of that impact. It is often transmitted directly to the brain.
Skull fractures are described by which bone is broken, whether there is an associated laceration of
the scalp, and whether the bone is depressed and potentially pushed into the brain tissue.

Brain injuries often occur in combination with one another. The effects of brain injury depend upon
the amount of brain tissue damaged and the level of pressure within the skull and its effects on the
brain.
What are the causes of a head injury?
By definition, trauma is required to cause a head injury, but that trauma does not necessarily need to
be violent. Falling down a few steps or falling into a hard object may be enough to cause damage.
Motor vehicle crashes account for more than 50% of traumatic brain injuries, with sports related
injuries adding another 20%. Almost 80% of head injuries occur in males.

Penetrating head injuries describe those situations in which the injury occurs due to a projectile, for
example a bullet, or when an object is impaled though the skull into the brain. Closed head injuries
refer to injuries in which no lacerations exist.

What are the symptoms of a head injury?

The symptoms of head injury can vary from almost none to loss of consciousness and coma. As
well, the symptoms may not necessarily occur immediately at the time of injury. While a brain injury
occurs at the time of trauma, it may take time for enough swelling or bleeding to occur to cause
symptoms that are recognizable.

Initial symptoms may include a change in mental status, meaning an alteration in the wakefulness of
the patient. There may be loss of consciousness, lethargy, and confusion.

Head injury symptoms may also include:

 vomiting,

 difficulty tolerating bright lights,

 leaking CSF from the ear or nose,

 bleeding from the ear ,

 speech difficulty,

 paralysis,

 difficulty swallowing, and

 numbness of the body.

Other symptoms may be more subtle and include:

 nausea,

 dizziness,
  irritability,

 difficulty concentrating and thinking, and

 amnesia.

Late signs of significant head injury and raised pressure within the brain and skull include a dilated
pupil, high blood pressure, low pulse rate, and abnormal breathing pattern.

Coma may be present if the patient doesn't waken completely and is defined as a prolonged episode
of loss of consciousness. There are different levels of coma, and the Glasgow Coma Scale is one
way of measuring its depth.

How can a head injury be prevented?

Prevention is the best way to treat a head injury.

 In sporting activities, the use of a helmet may help minimize the risk of injury; similarly,
wearing a helmet while riding a motorcycle or bicycle helps minimize the risk of brain injury.
Seatbelts can help prevent a head injury during a motor vehicle crash.

 Since alcohol is a risk factor for falls and other injuries, it should be used responsibly.

 Falls are a concern in the elderly. Homes can be made less fall-prone by installing assist
devices on walls and in bathrooms. Loose floor coverings such as area rugs should be avoided,
since walking from one floor covering to another increases the risk of falls. If needed, canes and
walkers may be helpful as walking assistive devices.