Head Injury

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What is a head injury?

A head injury is caused by any injury or wound (trauma) to the scalp, skull or brain. The trauma can be due to a fall, car accident, violence, or jolt. Head injuries are also caused by an object (bullet, shattered piece of skull) that goes through the skill and into brain tissue. The effects of the injury can affect your head temporarily, or cause physical damage to the brain, which can cause long-term effects, permanent damage or complications, even death. Older people, young children and males of any age have the highest risk of head injury. 

What are the different types of head injuries?

  • Scalp wounds can be caused by a variety of traumas, but do not usually affect the skull or brain.
  • Concussion is a head injury that can cause a loss of alertness or awareness for a few minutes to a few hours.
  • Skull fracture, which is caused by a break in the skull bone, can be one of these four major types:
    • Linear fracture, the most common type, is a break in the bone but the bone does not move. Patients should be watched but usually no other treatment is necessary.   
    • Depressed skull fracture causes a part of the skull to sink into the head due to the trauma. It can occur with or without a cut in the scalp, and may require surgery to correct it. 
    • Diastatic skull fracture occurs along and widens the skull’s suture lines (the areas between the bones that fuse in childhood). More common in infants.
    • Basilar skull fracture, the most serious type, is a break in the bone at the base of the skull. This type of fracture can cause nerve damage to cranial nerves, which can cause paralysis of face muscles, changes to your sense of smell or taste, changes in vision, dizziness, and swallowing problems. 
  • Intracranial hematoma is a blood clot in and/or around the brain. It can range from mild to life-threatening. The different types occur in different parts of the brain.
    • Epidural hematoma is a clot under the skull, on top of the covering that surrounds the brain, called the dura. Usually caused by a skull fracture, the cause is often a tear in an artery under the skull. 
    • Subdural hematoma is a clot under both the skill and the dura, but not in the brain. It can be caused by a tear in a vein, a cut in the brain, or skull fracture.
    • Contusion (intracerebral hematoma) is a bruise to the brain. It causes bleeding and swelling inside the brain at the site of the injury. Contusions can be caused by skull fractures, hematomas, chronic high-blood pressure, bleeding disorders, or taking blood-thinning medications or illegal drugs.
    • Diffuse axonal injury is caused by the brain being shaken back and forth, such as in a car accident, fall, or shaken-baby syndrome. Symptoms can range from a mild concussion to a coma caused by injuries in multiple parts of the brain.

 A head injury is also classified by whether it’s closed or open. A closed injury is the result of a hard blow but it does not break the skull. An open injury is a blow that breaks the skull and penetrates the brain. 

Why should I worry about head injury?

While most head injuries heal by themselves, a severe head injury can cause permanent damage, disability or even death. The physical, psychological and cognitive (intellectual) damages can become chronic and have a profound impact on the patient. Long-term treatment can be expensive and difficult for the patient to endure.

Causes

What causes head injury?

A direct blow to the head can bruise the brain, or tear internal lining, tissues, and blood vessels. This damage may cause internal bleeding or swelling of the brain. The process where the brain jolts against the side of the skull is called a coup-contrecoup. The bruise at the impact site is a coup lesion. As the brain jolts backwards, it can hit the skull on the opposite side and cause another bruise called a contrecoup lesion.   

Common causes of head injury include:

  • Falls are the most common cause, especially in older people and young children
  • Vehicle collisions – cars, motorcycles, bicycles, and pedestrians involved in these accidents
  • Violence involving guns, domestic violence, child abuse, and assaults
  • Sports injuries, especially high-impact sports in young people
  • Combat injuries and explosions cause a pressure wave through the brain that disrupts brain function

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Symptoms

What are the symptoms of head injury?

Head injuries can have wide-ranging physical and psychological effects. Some symptoms occur immediately after impact; other symptoms appear days or weeks after the injury.

Mild head injury can cause these physical symptoms:

  • Headache
  • Nausea or vomiting
  • Fatigue or drowsiness
  • Speech problems
  • Dizziness, loss of balance, vertigo
  • Blurred vision
  • Ringing in the ears
  • Bad taste in the mouth
  • Loss of or changes in ability to smell
  • Sensitivity to light or sound
  • Raised or swollen area on the head

Cognitive, behavioral or mental symptoms of mild head injury may include:

  • Loss of consciousness for a few seconds to a few minutes
  • Feeling dazed, confused or disoriented; slow to answer questions
  • Memory or concentration problems
  • Mood changes, mood swings, irritation
  • Depression or anxiety
  • Difficulty sleeping or sleeping too much

Moderate to severe head injuries can cause any of the mild head injury symptoms plus these additional symptoms:

  • Loss of consciousness from several minutes to hours, or a coma
  • Persistent or worsening headaches
  • Repeated vomiting or nausea
  • Sweating; pale skin color
  • Convulsions or seizures
  • Dilation of one or both pupils of the eyes
  • Drainage of clear fluid from nose or ears
  • Inability to awaken from sleep
  • Weakness or numbness in fingers and toes
  • Loss of coordination, difficulty walking
  • Weakness on one side or area of the body
  • Extreme confusion, or saying things that don’t make sense
  • Agitation, combativeness or other uncharacteristic behavior
  • Slurred speech
  • Loss of short-term memory, inability to remember what happened before and during the injury

Emotional changes related to moderate to severe head injury may include:

  • Depression
  • Anxiety
  • Mood swings
  • Irritability
  • Lack of empathy for others
  • Anger
  • Insomnia

Sensory problems can include:

  • Persistent ringing in the ears
  • Difficulty recognizing objects
  • Impaired hand-eye coordination
  • Blind spots or double vision
  • A bitter taste
  • A bad smell or difficulty smelling
  • Skin tingling, pain or itching
  • Trouble with balance or dizziness

Longer-term complications of severe head injury can include:

  • Hydrocephalus is fluid buildup in the brain causing increased brain swelling and pressure.
  • Infection caused by a penetrating wound that enables bacteria to enter the brain. Infected meninges (protective tissues that surround the brain) can cause meningitis. If untreated, meningitis can spread to the nervous system.
  • Blood vessel damage in the brain can lead to a stroke, blood clots or other problems.
  • Impaired thinking (cognitive) skills include taking longer to focus and process thoughts; problems with memory, learning, reasoning, judgment, and concentration; difficulty with problem-solving, planning, decision-making, and organization.
  • Long-term communication problems may include difficulty understanding speech or writing and speaking, problems participating in conversations, difficulty understanding nonverbal signals and reading listeners’ cues. 
  • Behavior problems can include difficulty with self-control, engaging in risky behavior, difficulty in social situations, verbal or physical outbursts, and lack of self-awareness.

Children’s symptoms can include:

  • Changes in eating or nursing habits
  • Unusual irritability
  • Persistent crying
  • Change in ability to pay attention
  • Change in sleep habits
  • Seizures
  • Drowsiness
  • Loss of interest in favorite toys or activities
  • Sad or depressed mood

How can I tell if my head injury is serious?

Doctors use a grade of 1 to 3 to assess head injury. 

  • Grade 1 is mild; symptoms last less than 15 minutes and you don’t lose consciousness. 
  • Grade 2 injury is moderate. Symptoms last longer than 15 minutes but no loss of consciousness. 
  • Grade 3 is severe; the person loses consciousness, even if it’s for just a few seconds.

Can a head injury cause mental illness?

The link between head injury and brain diseases is not clear. Researchers say repeated head injury or severe traumatic brain injury can increase the risk of degenerative brain diseases. This type of disease causes a gradual loss of brain functions and includes Alzheimer’s or Parkingson’s diseases, or dementia pugilistica (caused by repeated blows to the head in professional boxing).

Diagnosis

How is head injury diagnosed?

It’s important to get a diagnosis after a head injury. The full extent of the damage may not be evident immediately after the injury. It can be a medical emergency that rapidly gets worse without prompt treatment.

The emergency room doctor will complete a physical exam, listen to how the accident happened, and may assess the injury using the Glasgow Coma Scale. This diagnostic tool can assess the severity of the injury and is used by first responders and emergency personnel. It assesses the person's ability to follow directions, move their eyes and limbs, and speak coherently. The person’s abilities are scored from three (most severe) to 15 (least severe) on the Glasgow scale.  

The doctor may order diagnostic testing to determine the best treatment plan. Diagnostic tests can include:

  • Blood tests
  • X-rays to assess internal tissue and skull bones
  • Computed tomography scan (CT) can quickly provide images of fractures, bleeding in the brain (hemorrhage), blood clots, bruised brain tissue, and brain tissue swelling.
  • Electroencephalogram (EEG) records the brain’s continuous, electrical activity.
  • Magnetic resonance imaging (MRI) provides detailed images of organs and the body’s internal structures. It may be used after the patient is stabilized, or if symptoms don’t improve after the injury. 
  • Intracranial pressure monitor, via a probe through the skull, can monitor the pressure inside the skull, and detect swelling before it causes brain damage.

Treatment

How are head injuries treated?

Mild injuries usually don’t require treatment other than resting for a few days, a cold compress, and over-the-counter pain relievers for headaches. The patient should continue to be monitored for symptoms that aren’t getting better, or worsening symptoms.

Moderate to severe head injuries focus on maintaining enough oxygen and blood supply, normal blood pressure, and preventing further head or neck injury. Treatment focuses on minimizing secondary damage due to swelling, inflammation, bleeding or reduced oxygen to the brain. 

Treatment is determined by the severity of the injury, patient’s age, overall health, medical history, extent and type of injury, and patient’s tolerance for specific medication or procedures. Treatments may include:

Medications to limit secondary brain damage may include:

  • Anti-seizure drugs may be needed for a short while. A moderate to severe injury increases the risk of seizures during the first week after the injury. If seizures occur, the medication will be continued.
  • Coma-inducing drugs induce a temporary coma and are used because the brain needs less oxygen when in a coma. Increased pressure in the brain may compress blood vessels so they can’t supply adequate amounts of nutrients and oxygen to the brain. 
  • Diuretics can reduce the fluid in tissues and will help reduce pressure inside the brain. 

Surgery may be needed to reduce additional brain damage and address these problems:

  • Remove clotted blood that has collected from bleeding inside or outside the brain. The hematoma can put pressure on the brain and damage brain tissue. 
  • Repair a skull fracture or remove skull pieces from the brain.
  • Stop bleeding in the brain. 
  • Open a window in the skull to relieve pressure and/or to drain accumulated fluid.

Rehabilitation is usually needed by people who’ve had a significant brain injury. They may need to learn to walk and talk again, and relearn other basic self-care skills. Rehab can be provided in an inpatient rehab unit or through outpatient services. At rehab, the patient’s treatment team may include these rehab specialists:

  • Physiatrist, a doctor who specializes in physical medicine and rehab, oversees the rehab process and prescribes medications.
  • Occupational therapist helps the patient relearn everyday skills.
  • Physical therapist helps with mobility, relearning balance and walking.
  • Speech therapist helps improve communication skills.
  • Vocational counselor assesses the ability to return to work and provides information to help with workplace challenges.
  • Neuropsychologist assesses cognitive impairment, helps the patient manage behaviors, learn coping skills, and provide psychotherapy for emotional issues. 
  • Social worker/case manager ensures access to services, and acts as liaison between various professionals and family caregivers.

References

Mayo Clinic. (Feb. 2021). Traumatic brain injury. Retrieved 12-3-21, {https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557}
Mayo Clinic. (Feb. 2021). Traumatic brain injury diagnosis and treatment. Retrieved 12-3-21, {https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/diagnosis-treatment/drc-20378561}
Johns Hopkins Medicine. (N.d.). Head Injury. Retrieved 12-3-21, {https://www.hopkinsmedicine.org/health/conditions-and-diseases/head-injury}
MedlinePlus. (Sept. 2019). Head Injury First Aid. Retrieved 12-3-21, {https://medlineplus.gov/ency/article/000028.htm#:~:text=A%20head%20injury%20is%20any,did%20not%20break%20the%20skull.}

Information

Medically reviewed by:

Dr. Desiree Levyim

Dr. Desiree Levyim is a board eligible neurologist in practice since 2020. She joins TeleMed2U in our mission to provide increased access to healthcare.

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