A traumatic brain injury (TBI) happens when a sudden blow, jolt, or penetrating injury disrupts the way the brain normally works. It can follow a fall, a car crash, a sports collision, an assault, or any force strong enough to move or damage the brain inside the skull. Injuries range from mild, meaning a brief change in brain function, to severe, meaning bleeding, bruising, or torn tissue that can be life threatening. Even an injury labeled "mild," such as a concussion, is a real injury that deserves prompt attention.
Symptoms
Some symptoms appear right away. Others can show up hours, days, or even weeks later, so it helps to watch for changes over time. Symptoms generally track with how serious the injury is.
Mild TBI
- Headache, nausea, or vomiting
- Feeling tired, drowsy, dizzy, or off balance
- A brief loss of consciousness, or feeling dazed, confused, or disoriented without passing out
- Blurred vision, ringing in the ears, a bad taste in the mouth, or changes in the sense of smell
- Sensitivity to light or sound
- Trouble with memory or concentration
- Mood changes, anxiety, or feeling depressed
- Sleeping more than usual, or trouble sleeping
Moderate to severe TBI
These injuries can include any of the symptoms above, along with more serious signs that often appear within the first hours to days:
- Loss of consciousness lasting several minutes to hours
- A headache that will not go away or keeps getting worse
- Repeated vomiting or nausea
- Seizures or convulsions
- Widening (dilation) of one or both pupils
- Clear fluid draining from the nose or ears
- Inability to wake from sleep
- Weakness or numbness in the fingers and toes, or loss of coordination
- Profound confusion, agitation, combative or unusual behavior, or slurred speech
- Coma
Symptoms in infants and young children
Young children may not be able to describe how they feel, so caregivers should watch for:
- Changes in eating or nursing habits
- Unusual irritability, or persistent crying that cannot be soothed
- Changes in attention, sleep habits, or mood
- Drowsiness, seizures, or loss of interest in favorite toys or activities
Causes
A TBI is caused by a force that strikes or shakes the head or body, or by an object that pierces the skull. Common causes include:
- Falls. The most common cause overall, especially in older adults and young children.
- Motor vehicle crashes. Collisions involving cars, motorcycles, and bicycles, including those affecting pedestrians.
- Violence. Gunshot wounds, assaults, domestic violence, and child abuse, including shaken baby syndrome in infants.
- Sports injuries. Contact and high-impact sports such as football, soccer, boxing, hockey, and skateboarding.
- Blast injuries. A common cause of TBI among active-duty military personnel.
Some people face a higher risk, including young children, teenagers and young adults, adults over 60, and males in any age group.
When to seek emergency care
Call 911 or go to an emergency room if you or someone else shows any sign of a moderate to severe TBI after a blow to the head, such as repeated vomiting, seizures, a worsening headache, clear fluid draining from the nose or ears, weakness, slurred speech, or any loss of consciousness. Always contact a doctor after a head injury that concerns you or causes a change in behavior. A person does not need to lose consciousness to have a serious brain injury.
How a TBI is diagnosed
Because a TBI can worsen quickly, evaluation often begins right away. Doctors and first responders may use:
- The Glasgow Coma Scale. A 15-point check of eye movement, speech, and the ability to follow directions. Higher scores point to a less severe injury.
- CT scan. Usually the first imaging test in the emergency room. It quickly shows fractures, bleeding, blood clots, bruising, and swelling.
- MRI. A more detailed scan, often used once the person is stable or if symptoms do not improve.
- Intracranial pressure monitoring. A small probe placed through the skull to measure pressure inside the head, since swelling can cause further damage.
One thing a CT scan looks for is bleeding between the brain and the skull, which a blow to the head can cause by tearing blood vessels. Two common types are an epidural hematoma, where blood collects between the skull and the dura, the brain's tough outer covering, and a subdural hematoma, where blood collects beneath the dura on the surface of the brain. As blood builds up it can press on the brain, which is one reason a worsening headache, increasing drowsiness, or repeated vomiting after a head injury needs emergency care. When bleeding is significant, surgery may be needed to remove the blood and relieve pressure.
Treatment
Treatment depends on how serious the injury is.
Mild TBI
Most mild injuries need rest and over-the-counter pain relievers for headache, along with close monitoring at home for any new or worsening symptoms. Doctors usually recommend "relative rest," which means easing back from physical and mental activities that make symptoms worse rather than resting completely. Most people return to normal routines gradually, and a doctor advises when it is safe to go back to work, school, or sports.
Moderate to severe TBI
Emergency care focuses on keeping enough oxygen and blood flowing to the brain, maintaining blood pressure, and preventing further injury to the head and neck. The goal is to limit secondary damage from bleeding, swelling, or reduced oxygen. Medications may include:
- Anti-seizure drugs to prevent seizures during the first week, when the risk is highest.
- Diuretics to reduce fluid and lower pressure inside the brain.
- Coma-inducing drugs in some cases, because a brain in a temporary, medically controlled coma needs less oxygen.
Surgery
Emergency surgery is sometimes needed to protect the brain from further damage. A neurosurgeon may operate to:
- Remove a collection of clotted blood (hematoma) that is pressing on the brain
- Stop bleeding inside the brain
- Repair a skull fracture
- Relieve pressure inside the skull, by draining fluid or removing a section of bone to give swollen tissue more room (decompression)
Rehabilitation and recovery
Many people with a significant TBI need rehabilitation to regain skills such as walking, talking, and managing daily activities. Care is delivered by a team that may include a physiatrist (a physical medicine and rehabilitation physician), rehabilitation nurses, and physical, occupational, and speech therapists. Therapy often begins in the hospital and continues in an inpatient unit or through outpatient services. The type and length of rehabilitation depend on the severity of the injury and which part of the brain was affected. Recovery can take months to years, with the most progress usually in the first year.
Prevention
Many brain injuries can be prevented. Wear a seat belt and use age-appropriate car seats for children, wear a helmet for biking and contact sports, and never drive under the influence of alcohol or drugs. To reduce falls at home, improve lighting, add handrails and nonslip mats, and keep stairs and floors clear of clutter.
Care at UPMC/Pitt Neurosurgery
Neurosurgeons at UPMC/Pitt Neurosurgery evaluate and treat traumatic brain injuries, ranging from concussion to severe injury that requires surgery. To learn more about our team, visit our faculty directory.