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24-18: Head Injury

Vanja C. Douglas; Michael J. Aminoff

Trauma is the most common cause of death in young people, and head injury accounts for almost half of these trauma-related deaths. Head injury severity ranges from concussion to severe traumatic brain injury (TBI). Concussion is broadly defined as an alteration in mental status caused by trauma with or without loss of consciousness. The term concussion is often used synonymously with mild TBI. Grades of TBI are traditionally defined by the Glasgow Coma Scale (GCS) measured 30 minutes after injury (Table 24–7).

Table 24–7.Glasgow Coma Scale.1
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Table 24–7. Glasgow Coma Scale.1
Points Eye Opening Verbal Response Motor Response
1 None None None
2 To pain Vocal but not verbal Extension
3 To voice Verbal but not conversational Flexion
4 Spontaneous Conversational but disoriented Withdraws from pain
5 Spontaneous Oriented Localizes pain
6 Spontaneous Oriented Obeys commands

1GCS score indicating severity of traumatic brain injury (TBI): mild, 13–15; moderate, 9–12; severe, ≤ 8.

Reproduced, with permission, from Aminoff MJ et al. Clinical Neurology, 9th ed, McGraw-Hill Education, 2015; Data from Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;304:81–4.

Head trauma may cause cerebral injury through a variety of mechanisms (Table 24–8). Central to management is determination of which patients need head imaging and observation. Of particular concern is identification of patients with epidural and subdural hematoma, who may present with normal neurologic findings shortly after injury (lucid interval) but rapidly deteriorate thereafter, and in whom surgical intervention is life-saving.

Table 24–8.Acute cerebral sequelae of head injury (listed in alphabetical order).
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Table 24–8. Acute cerebral sequelae of head injury (listed in alphabetical order).
Sequelae Clinical Features Pathology
Acute epidural hemorrhage Headache, confusion, somnolence, seizures, and focal deficits occur several hours after injury (lucid interval) and lead to coma, respiratory depression, and death unless treated by surgical evacuation. Tear in meningeal artery, vein, or dural sinus, leading to hematoma visible on CT scan.
Acute subdural hemorrhage Similar to epidural hemorrhage, but interval before onset of symptoms is longer. Neurosurgical consultation for consideration of evacuation. Hematoma from tear in veins from cortex to superior sagittal sinus or from cerebral laceration, visible on CT scan.
Cerebral contusion or laceration Loss of consciousness longer than with concussion. Focal neurologic deficits are often present. May lead to death or severe residual neurologic deficit.

Bruising on side of impact (coup injury) or contralaterally (contrecoup injury).

Vasogenic edema, multiple petechial hemorrhages, and mass effect. May have subarachnoid bleeding. Herniation may occur in severe cases. Cerebral laceration specifically involves tearing of the cerebral tissue and pia-arachnoid overlying a contusion.
Cerebral hemorrhage Generally develops immediately after injury. Clinically resembles hypertensive hemorrhage. Surgery to relieve mass effect is sometimes necessary. Hematoma, visible on CT scan.
Concussion A transient, trauma-induced ...

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