Traumatic brain injury

Changed by James Condon, 30 Jan 2017

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Traumatic brain injuries (TBI) are common and come with a large cost to both society and the individual. Imaging plays a key role in accurate diagnosis, classification and follow-up.

Epidemiology

TBI are more common in young patients, and men account for the majority (75%) of cases ⁴.

Clinical presentation

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

mild TBI: GCS 14-15
moderate TBI: GCS 9-13
severe TBI: GCS 3-8

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

Pathology

In the acute setting patients can present with primary brain damage ⁴:

traumatic subarachnoid haemorrhage (tSAH)
subdural haematoma (SDH)
extradural haematoma (EDH)
intraventricular haemorrhage
cerebral haemorrhagic contusion
- intermediary injury
diffuse axonal injury (DAI)

Secondary brain damage can also occur and manifests as ⁴:

generalised cerebral oedema
hypoxic-ischaemic brain injury
ischaemic stroke from traumatic arterial dissection

Long-term sequelae of head trauma includes:

encephalomalacia/gliosis
chronic subdural haematomas / CSF hygromas
chronic traumatic encephalopathy

Depression, anxiety and alcohol abuse ⁵

Increased risk of schizophrenia, bipolar disorder and organic mental disorders ⁶

Aetiology

TBI has been traditionally divided into closed and penetrating head injuries ⁴:

closed head injury
- blunt trauma: motor vehicle collision, assault, sport, industrial/workplace accidents, etc
- blast injuries
- non-accidental injury in children
penetrating head injury
- gunshot injuries, stabbing

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 ⁵⁷
skull fracture
facial fracture
pneumocephalus
extracranial injuries in 35% ⁴

Radiographic features

CT is the workhorse of imaging in TBI, especially in the acute setting, and is used in most settings to classify the degree of injury using imaging (see main article: Marshall classification of traumatic brain injury).

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. Please see the relevant articles for imaging findings.

Classification

A number of classifications have been described, variably using clinical or imaging parameters. These include:

Treatment and prognosis

Large haematomas 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.

+<li>Depression, anxiety and alcohol abuse 5
+</li>
+<li>Increased risk of schizophrenia, bipolar disorder and organic mental disorders 6
+</li>
~~-<a href="/articles/cervical-spine-injury">cervical spine injury</a>: patients with GCS <8 are most at risk 5~~
+<a href="/articles/cervical-spine-injury">cervical spine injury</a>: patients with GCS <8 are most at risk 7

References changed:

5. Fann JR, Hart T, Schomer KG. Treatment for depression after traumatic brain injury: a systematic review. (2009) Journal of neurotrauma. 26 (12): 2383-402. <a href="https://doi.org/10.1089/neu.2009.1091">doi:10.1089/neu.2009.1091</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19698070">Pubmed</a>
5. Fann JR, Hart T, Schomer KG. Treatment for depression after traumatic brain injury: a systematic review. (2009) Journal of neurotrauma. 26 (12): 2383-402. <a href="https://doi.org/10.1089/neu.2009.1091">doi:10.1089/neu.2009.1091</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19698070">Pubmed</a>
6. Orlovska S, Pedersen MS, Benros ME, Mortensen PB, Agerbo E, Nordentoft M. Head injury as risk factor for psychiatric disorders: a nationwide register-based follow-up study of 113,906 persons with head injury. (2014) The American journal of psychiatry. 171 (4): 463-9. <a href="https://doi.org/10.1176/appi.ajp.2013.13020190">doi:10.1176/appi.ajp.2013.13020190</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24322397">Pubmed</a>
6. Orlovska S, Pedersen MS, Benros ME, Mortensen PB, Agerbo E, Nordentoft M. Head injury as risk factor for psychiatric disorders: a nationwide register-based follow-up study of 113,906 persons with head injury. (2014) The American journal of psychiatry. 171 (4): 463-9. <a href="https://doi.org/10.1176/appi.ajp.2013.13020190">doi:10.1176/appi.ajp.2013.13020190</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24322397">Pubmed</a>
7. Holly LT, Kelly DF, Counelis GJ et-al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J. Neurosurg. 2002;96 (3 Suppl): 285-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11990836">Pubmed citation</a>
5. Holly LT, Kelly DF, Counelis GJ et-al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J. Neurosurg. 2002;96 (3 Suppl): 285-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11990836">Pubmed citation</a>
5. Fann JR, Hart T, Schomer KG. J Neurotrauma. Treatment for Depression after Traumatic Brain Injury: A Systematic Review, 2009 Dec; 26(12): 2383–2402
6. Holly LT, Kelly DF, Counelis GJ et-al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J. Neurosurg. 2002;96 (3 Suppl): 285-91. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11990836">Pubmed citation</a>

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