Traumatic Brain

injury
Traumatic brain injury (TBI)
has a broad spectrum of
severity, pathology,
physiology, and sequela.
PRIMARY VERSUS SECONDARY
INJURY
• Physiological or
anatomical insult
Primary • Cause tissue distortion,
shearing, and vascular
injury

• systemic or local changes

• excitotoxicity, disturbance of
Secondary ionic homeostasis, disruption of
the blood–brain barrier,
mitochondrial dysfunction and
inflammation secondary
CLASSIFICATION
OF TBI BY
MECHANISM
 • Injury caused by direct force to
head, acceleration–
Closed/blunt deceleration, or rotational
force forces. Common causes include
falls, assaults, and motor
vehicle collisions.
• Injury caused by overpressure waves
generated from high-grade
explosives. A large amount of thermal,
Blast injury mechanical, and electromagnetic
energy is transferred to the brain.
• cerebral edema, axonal injury,
apoptosis, and tissue degeneration.

• injury induced by an object that

Penetrating penetrates the cranial vault.
injury • gunshot wounds, shrapnel, and
knife wounds
CLINICAL CLASSIFICATION
OF TBI
 • GCS 13 to 15, the majority of patients
Mild TBI with cranial trauma fall in this group.
• Patients are awake, and may be
(MTBI) confused but can communicate and
follow commands.

• GCS 9 to 12, these patients are

generally drowsy to obtunded but not
Moderate comatose.
• They can open their eyes and localize
TBI painful stimuli. They are at high risk of
clinical deterioration and must be
monitored carefully.

• GCS 3 to 8, these patients are

Severe obtunded to comatose, they do not
follow commands and may exhibit
TBI decerebrate or decorticate posturing.
 STRUCTURALLY BASED
DESCRIPTIONS OF TBI

Structural descriptions incorporate

information from imaging studies.
They often aide in selection of
patients who may benefit from a
specific therapy such as surgical
evacuation of a hematoma.
 Traumatic
Epidural Subdural Diffuse subarachnoid
hematoma hematoma axonal injury hemorrhage
(EDH) (SDH) [DAI] (TSAH or
SAH)

Injury to
Collection of Hemorrhage
Extradural axonal
blood in the in the
collection of connections
subdural subarachnoid
blood triggered by
space space
inertial forces

Associated Caused by
Acceleration/ It often
with a skull venous
deceleration accompanies
fracture and bleeding
leads to other types
typically has from cortical
mechanical of traumatic
an arterial bridging
deformation hemorrhage
origin veins
EPIDURAL HEMATOMA
SUBDURAL HEMATOMA
INTRAVENTR
ICULAR SKULL
CONTUSION CONCUSSION
HEMORRHA FRACTURES
GE (IVH)

Bleeding parenchymal altered

into the hemorrhage, because of mental
ventricular typically in blunt or state
system frontal or penetratin occurring
after temporal g injury. after
lobes.
trauma. trauma

open or may or
closed/ may not
Associated
depressed include
with acute Coup / centre
coup injury skull brief loss
hydroceph
fractures of
alous
may lead conscious
to seizures ness
CEREBRAL CONTUSION
 POST TRAUMATIC AMNESIA
Posttraumatic amnesia (PTA) is
the impaired recall of events
surrounding the injury.

Retrograde PTA involves impaired

recollection of events immediately
preceding the injury
Anterograde PTA is a deficit in
forming new memories after the
 POSTCONCUSSION DISORDER
This term refers to postconcussive
symptoms that persist for 3 or more
months postinjury.
 SECOND-IMPACT SYNDROME

A second MTBI occurring while an

individual remains symptomatic from the
first MTBI may cause the “second-impact
syndrome.”
This rare phenomenon involves acute
cerebrovascular congestion and loss of
cerebrovascular autoregulation resulting
in malignant brain swelling, which is life
threatening
Concussion and Mild Traumatic
Brain Injury: Definitions,
Distinctions, and
Diagnostic Criteria
Complex Interwoven Cellular And Vascular
Changes That
Hot Air Balloon and CloudsOccur Following Mild TBI
(MTBI)
Abnormal
Ionic energy
shifts metabolism

Impaired
Diminished neurotransmis
cerebral blood sion
flow

20
MTBI may or may not result in macrostructural
brain damage visible on computed tomography
(CT) or magnetic resonance imaging
(MRI).
Concussion is the preferred term in sport.
Much of the sports medicine literature uses
the more precise phrase “sport-related
concussion.” Because concussions in sport
typically fall on the milder end of the
MTBI spectrum
There is no universally agreed-upon definition
of MTBI
Mild Traumatic Brain Injury: Initial Medical
Evaluation and Management
Symptoms
Red Flag symptoms in patients with MTBI
include:
• Neurologic signs shown to have a
significantly high-positive likelihood ratio
for ICI include persistent short-term memory
deficits, seizures, deterioration in
mental status, GCS less than 14, and focal
neurological deficit [1,19].
• Repeated vomiting has a high-positive
likelihood ratio for ICI in patients with
MTBI [20].
• Headache (particularly if severe or
persistent) has been associated with a small
but significant increased risk of ICI in MTBI
[1,19]. Headache can also be the
presenting complaint in carotid dissection.
• Neck pain, though most commonly due to
mechanical soft tissue injury, should
trigger the clinician to consider cervical
fractures, or carotid or vertebral artery
dissection.