Craniocerebral Injury

Craniocerebral injury, also known as traumatic brain injury, affects thousands of people every year when the brain is damaged by an outside force. This injury can range from mild to severe, with effects that may last days, months, or even a lifetime.

Table of contents

• What is craniocerebral injury?
• Types of injury
• What causes craniocerebral injury?
• Symptoms and warning signs
• When to seek medical attention
• How is it diagnosed?
• Treatment approaches
• Recovery and living with brain injury
• Preventing craniocerebral injury

What is craniocerebral injury?

Craniocerebral injury, commonly called traumatic brain injury (TBI), refers to a brain injury caused by an outside force. This happens when a forceful bump, blow, or jolt to the head or body causes the brain to move rapidly back and forth inside the skull^[2]. An object entering the brain, such as a bullet or shattered piece of skull, can also cause this type of injury^[1].

When the brain moves suddenly inside the skull, it can bounce around or twist, creating chemical changes in the brain and sometimes stretching and damaging brain cells^[4]. Not all blows or jolts to the head result in a traumatic brain injury^[2].

Every 9 seconds, someone in the United States sustains a brain injury^[3]. These injuries are a major cause of death and disability, affecting how a person thinks, acts, and feels^[9]. The effects can be wide ranging and can change everything about someone in a matter of seconds^[3].

Types of injury

Craniocerebral injuries can be classified in several ways. Healthcare providers first categorize them as either closed or open injuries^[5].

A closed head injury, also called non-penetrating or blunt TBI, occurs when something hits the head hard enough that the brain bounces or twists around inside the skull, but nothing breaks through the skull. This type can happen from falls, motor vehicle crashes, sports injuries, blast injuries, or being struck by an object^[2]. Most head injuries are closed injuries^[5].

An open head injury, also known as penetrating TBI, happens when an object pierces the skull and enters the brain tissue. This usually requires severe trauma, such as from a bullet, shrapnel, or bone fragment^[2]. Penetrating TBI typically damages only part of the brain^[2].

Some accidents or trauma can cause both penetrating and non-penetrating TBI in the same person^[2].

Healthcare providers also classify traumatic brain injuries based on severity: mild, moderate, and severe^[9]. More than 75% of all TBIs are mild^[9]. A concussion is a type of mild traumatic brain injury^[4]. However, even mild TBIs may cause significant and long-term issues^[9].

Some TBIs are considered primary, meaning the damage is immediate. Others can be secondary, meaning they happen gradually over hours, days, or weeks after injury. These secondary TBIs result from reactive processes that occur after the initial head trauma^[2].

What causes craniocerebral injury?

Any strong force or impact can cause a head injury^[5]. Traumatic brain injury usually results from a violent blow or jolt to the head or body^[1].

Common causes include falls, motor vehicle crashes, sports injuries, blast injury, or being struck by an object^[2]. Falls are the most common cause of brain injuries, especially among younger and older people^[19]. In 2020, more than 214,000 people needed in-patient care for a TBI, and more than 69,000 people died from issues involving traumatic brain injury^[9].

Symptoms and warning signs

Traumatic brain injury can have wide-ranging physical and psychological effects. Some signs or symptoms may appear immediately after the traumatic event, while others may appear days or weeks later^[1]. It can take hours, days, or even weeks to start noticing signs or symptoms^[5].

Headache, dizziness, confusion, and fatigue tend to start immediately after an injury but resolve over time. Emotional symptoms such as frustration and irritability tend to develop during recovery^[2].

Mild traumatic brain injury symptoms

The signs and symptoms of mild traumatic brain injury may include^[1][6]:

• Headache
• Nausea or vomiting
• Fatigue or drowsiness
• Problems with speech
• Dizziness or loss of balance
• Raised, swollen area from a bump or bruise
• Small, superficial cut in the scalp

Sensory symptoms may include blurred vision, ringing in the ears, a bad taste in the mouth, or changes in the ability to smell. People may also experience sensitivity to light or sound^[1][6].

Cognitive, behavioral, or mental symptoms can include loss of consciousness for a few seconds to a few minutes, or a state of being dazed, confused, or disoriented. Memory or concentration problems, mood changes or mood swings, feeling depressed or anxious, difficulty sleeping, or sleeping more than usual may also occur^[1][6].

Moderate to severe traumatic brain injury symptoms

Moderate to severe traumatic brain injuries can include any of the signs and symptoms of mild injury, as well as these symptoms that may appear within the first hours to days after a head injury^[1][6]:

• Loss of consciousness from several minutes to hours
• Persistent headache or headache that worsens
• Repeated vomiting or nausea
• Convulsions or seizures
• Severe headache that does not go away
• Loss of short-term memory
• Slurred speech
• Difficulty with walking
• Weakness in one side or area of the body
• Sweating
• Behavior changes including irritability
• Blood or clear fluid draining from the ears or nose
• One pupil looks larger than the other eye
• Deep cut or laceration in the scalp
• Open wound in the head
• Foreign object penetrating the head
• Unequal eye pupil size or dilation
• New neurological problems such as slurred speech, weakness of arms, legs, or face, or loss of balance

When to seek medical attention

Many head injuries don’t cause symptoms right away, especially closed head injuries that may be harder to notice at first^[5]. Visit a healthcare provider or go to the emergency room if you know you experienced a head injury or trauma and start experiencing symptoms, even if you don’t notice them right away^[5].

Seek immediate medical attention if a person experiences any of the following symptoms, especially within the first 24 hours after an injury to the head^[2][5]:

• A headache that gets worse or does not go away
• Repeated vomiting or nausea
• Convulsions or seizures
• An inability to wake up
• Dilated pupil in one or both eyes
• Slurred speech
• Weakness or numbness in the arms or legs
• Loss of coordination
• Increased confusion, restlessness, or agitation

A child with a concussion needs to be seen by a health care provider^[4]. You might feel anxious, afraid, or uncertain if you think your child may have experienced a concussion. These feelings are normal^[4]. Getting care from a health care provider can help speed recovery^[4].

How is it diagnosed?

Traumatic brain injuries may be emergencies. In the case of more severe TBIs, consequences can worsen rapidly without treatment. Doctors or first responders need to assess the situation quickly^[8].

Healthcare providers use a neurologic exam and imaging tests to make a diagnosis^[7]. Doctors use a 15-point test called the Glasgow Coma Scale to help assess the initial severity of a brain injury by checking a person’s ability to follow directions and move their eyes and limbs. The coherence of speech also provides important clues. Abilities are scored from three to 15, with higher scores meaning less severe injuries^[8].

If you saw someone sustain an injury or arrived immediately after an injury, you may be able to provide medical personnel with useful information, such as how the injury occurred, whether the person lost consciousness and for how long, and any other changes in alertness, speaking, coordination, or other signs of injury^[8].

Imaging tests

Computerized tomography (CT) scan is usually the first test performed in an emergency room for a suspected traumatic brain injury. A CT scan uses a series of X-rays to create a detailed view of the brain. It can quickly visualize fractures and uncover evidence of bleeding in the brain, blood clots, bruised brain tissue, and brain tissue swelling^[8].

Magnetic resonance imaging (MRI) uses magnets, radio waves, and a computer to image the body’s soft tissues. An MRI may be used after a person’s condition stabilizes or if symptoms don’t improve soon after the injury^[8].

Treatment approaches

Treatment for brain injury is individualized, depending on the extent of the condition and the presence of other issues^[6]. Just as no two people are exactly alike, no two brain injuries are exactly alike. This is important to keep in mind when addressing brain injury treatment^[10].

Mild traumatic brain injury treatment

Most head injuries are mild head injuries. Most people presenting with mild head injuries will not have any progression of their injury; however, a small percentage of mild head injuries progress to more serious injuries^[12].

Patients with mild to moderate headaches, dizziness, and nausea are considered to have low-risk injuries. Many of these patients require only minimal observation after they are assessed carefully, and many do not require radiographic evaluation^[12].

Patients who are discharged after mild head injury should be given an instruction sheet for head injury care. The sheet should explain that the person with the head injury should be awakened every 2 hours and assessed neurologically. Caregivers should be instructed to seek medical attention if patients develop severe headaches, persistent nausea and vomiting, seizures, confusion or unusual behavior, or watery discharge from either the nose or the ear^[12].

Post-concussive syndrome

As many as 30% of patients who experience a concussion develop post-concussive syndrome (PCS). PCS consists of a persistence of any combination of the following after a head injury: headache, nausea, vomiting, memory loss, dizziness, double vision, blurred vision, emotional instability, or sleep disturbances. Fixed neurologic deficits are not part of PCS^[12].

PCS usually lasts 2 to 4 months. Typically, the symptoms peak 4 to 6 weeks following the injury. On occasion, the symptoms of PCS last for a year or longer. Approximately 20% of adults with PCS will not have returned to full-time work 1 year after the initial injury, and some are disabled permanently by PCS. PCS tends to be more severe in children than in adults^[12].

Moderate to severe TBI treatment

Treatment modalities vary extensively based on the severity of the injury and range from daily cognitive therapy sessions to radical surgery such as bilateral decompressive craniectomies^[11]. More serious traumatic brain injury can result in bruising, torn tissues, bleeding, and other physical damage to the brain. These injuries can result in long-term complications or death^[1].

Brain injury requires access to a full continuum of treatment and community-based supports provided by appropriately educated clinicians serving on an interdisciplinary team. Treatment can be acute or post-acute. Acute treatment involves care that an individual receives in the hospital immediately after their injury, while post-acute care encompasses long-term treatment for persisting side effects of brain injury^[10].

Recovery and living with brain injury

With proper care, most people can return to work, school, and many other activities within a few days or weeks after a mild TBI or concussion^[18]. However, some children have symptoms that affect their behavior, mood, memory, or emotions for months or longer^[4]. Most children with a concussion feel better within 2 to 4 weeks^[4].

Recovery from a mild TBI or concussion means you can do your regular activities without experiencing symptoms. Recovery may be slower among older adults, young children, and people who have had a concussion or other TBI in the past^[18].

Steps to support recovery

The first few days after injury, resting is good as this is when symptoms are more severe. You may need to take a short time off from work or school, although usually no more than 1 to 2 days^[18].

After one or two days of rest, it’s important to ease back into your regular activities even if you still have some mild symptoms. If your symptoms get worse, you should cut back on that activity^[18]. Find relaxing activities like reading and taking a short walk with a friend. Start light physical activity, such as taking a short walk^[18].

When symptoms are nearly gone, you can return to most of your regular activities^[18]. Taking these steps may help speed recovery^[18]:

• Avoid activities that can put you at risk for another injury to your head and brain, such as playing sports
• Stay connected to friends and loved ones and talk with them about how you are feeling
• Talk with your employer about support services to help you get back to work safely
• Ask your healthcare provider about medications that are safe to take during recovery
• Limit screen time and loud music before bed, sleep in a dark room, and keep to a fixed bedtime and wake-up schedule

Practical tips for daily life

People living with brain injury can benefit from several practical strategies^[17][20]:

• Get plenty of sleep at night and rest during the day
• Avoid activities that are physically demanding or require a lot of concentration, as they can make symptoms worse and slow recovery
• Write down things that may be harder than usual to remember
• If easily distracted, try to do one thing at a time
• Keep a detailed calendar of things you do and plan to do
• Consult with family members or close friends when making important decisions
• Do not neglect basic needs, such as eating well and getting enough rest
• Avoid sustained computer use, including computer and video games, early in the recovery process
• Take only those drugs that your healthcare provider has approved
• Do not drink alcoholic beverages until your healthcare provider says you are well enough

When symptoms persist

Talk with your healthcare provider if symptoms don’t go away within 2 to 3 weeks, or get worse after you return to your regular activities^[18]. Some people will have symptoms for months or longer^[18].

Anxiety and depression may make it harder to adjust to the symptoms of a mild TBI or concussion^[18]. If you have one or more symptoms that last months after the injury, your healthcare provider may talk to you about post-concussive syndrome^[18].

Preventing craniocerebral injury

There are several things you can do to help prevent concussions and reduce the risk and severity of damage if an injury does occur^[4].

Home safety measures

Trips and falls are the most common causes of brain injuries, especially among younger and older people. Even in your home, tripping can lead to hitting your head on a hard floor, against the wall, or on a piece of furniture^[19].

To reduce the risk of falls at home^[19]:

• Improve home lighting to ensure the best visibility for potential hazards, including furniture, uneven surfaces, or clutter
• Always use handrails for stability as you go up and down stairs
• Install handrails at home that should be regularly assessed for damage
• Consider adding handrails in the bathroom, particularly for the bathtub, to reduce the risk of slipping on wet surfaces

Physical preparation

Since falls can lead to brain injuries, you can add exercises into your everyday routine and workout regimen to decrease the likelihood of falling. Stretching muscles in the morning when you get out of bed can help. You can incorporate exercises that improve balance, such as weight shifts and single-leg balances. Muscle strengthening exercises, such as single-leg squats, can also reduce the risk of falling^[19].

Protective equipment

Always wear a helmet during recreational activities. Everyone in the family should wear properly fitted helmets when riding bicycles, skateboarding, or participating in contact sports^[19].

Avoiding repeat injuries

Exposure to repeated head impacts increases the chance for concussions and other TBIs, as well as the potential for changes in the brain and brain diseases^[4]. There’s a bigger risk of more serious and longer-lasting symptoms when a person has multiple concussions. This is especially true when there’s not enough healing time between injuries^[4].

A child with a history of multiple concussions may have ongoing problems with concentration, memory, and headaches; physical problems such as keeping their balance; and a greater risk for mental health problems and other chronic health conditions^[4].