Traumatic Brain Injury

Traumatic brain injury (TBI) is defined as a structural injury to the brain or a disruption in the
normal functioning of the brain as a result of a blunt or penetrating head injury.
● Primary Brain Injury - occurs at the time of the trauma as an immediate consequence of
head injury (cortical contusions, lacerations, bone fragmentation, diffuse axonal injury,
and brainstem contusion)
● Secondary Brain Injury - indirect brain injury that results from physiological changes
following acute CNS insults and or their treatment (hemorrhagic stroke, ischemic stroke,
TBI, traumatic spinal cord injury
Severity of TBI:
● Mild TBI: GCS 14-15
● Moderate TBI: GCS 9-13
● Severe TBI: GCS <8
Characteristic manifestations of Mild TBI:

● GCS ≥ 13–15
● transient loss of consciousness,
● altered mental status at the time of injury,
● posttraumatic amnesia
● Minor neurological abnormalities that do not require surgical intervention (transient focal
neurological signs/symptoms, self-limited seizure, small or benign traumatic intracranial
lesion/bleeding that does not require surgical intervention)
Indications for giving Mannitol
1.evidenceofintracranialhypertension(see▶Table51.2)
2.evidenceofmasseffect(focaldeficit,e.g.hemiparesis)
3.suddendeteriorationpriortoCT(includingpupillarydilatation)
4. after CT, if a lesion that is associated with increased ICP is identified
5. after CT, if going to O.R.
6. toassess “salvageability”: in patient with no evidence of brainstem function, look for return of
brainstem reflexes
bolus with 0.25–1 gm/kg over<20min (for average adult: ≈ 350ml of 20% solution). Peak effect occurs in
≈ 20minutes (for follow-up dosing).
Canadian CT Head rules:

High risk factors (for neurological intervention:
● GCS <15 at 2 hours post-injury
● Suspected open skull fracture
● Signs of basal skull fracture
● >2 episodes of vomiting
● Age >65yo
Medium risk factors ( for brain injury on CT):

● Amnesia before impact >30mins
● Dangerous mechanism of injury
Etiologies of TBI:
● Blunt head injury (common): injury caused by blunt force trauma to the head
Falls: leading cause of TBI; more common in children, adolescents, and the elderly [7]
Motor vehicle accidents: second most common cause of TBI [7]
Contact sports (e.g., football)
● Penetrating head injury (less common): injury caused by penetrative trauma to the head
[8]
High-velocity missile injury: gunshot wounds
Low-velocity nonmissile injury: assault or accidental injury with a penetrating foreign body to the
head or face (e.g., knife, screwdriver, nail gun) [9][10]
● Blast injuries: injury caused by the high pressure wave (blast wave) generated from an
explosion; common in active military or war zones
PATHOPHYSIOLOGY:
TBI is categorized pathophysiologically into primary and secondary brain injury depending on
whether the brain injury is a direct or indirect result of the inciting trauma.
● Primary brain injury [12][13]
1. Focal primary brain injury
● Intracranial hemorrhage - broad term used to describe any bleeding
within the skull
○ Epidural hemorrhage (EDH) - bleeding between the dura mater
and the skull
○ Subdural hemorrhage (SDH) - bleeding into the intracranial
subdural space typically caused by a rupture of bridging veins
○ Subarachnoid hemorrhage (SAH) - bleeding into the subarachnoid
space
○ Intracerebral hemorrhage (ICH) - bleeding within the brain
parenchy
○
○ Cerebral contusion: focal area of heterogeneous brain injury,
varying from a bruise to a focal area of necrosis [14]
Coup-contrecoup injury
● Coup injury: injury on the side of an impact
● Contrecoup injury: additional injury (typically a contusion) on the opposite side of impact
Brain parenchymal lacerations
Intracerebral or intracerebellar hematoma
1. Diffuse primary brain injury
● Mild traumatic brain injury (concussion)
Cerebral edema
Diffuse axonal injury (DAI)
Multifocal shearing tears and disruption of the axons of the brain due to rotational acceleration-
deceleration trauma of the head; typically seen in high-impact road traffic accidents. [15][16]
Commonly results in severe neurological injury (e.g., coma, persistent vegetative state)

Traumatic Brain Injury

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Traumatic brain injury (TBI) is defined as a structural injury to the brain or a disruption in the

normal functioning of the brain as a result of a blunt or penetrating head injury.

Characteristic manifestations of Mild TBI:

Canadian CT Head rules:

Medium risk factors ( for brain injury on CT):

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