A traumatic brain injury (TBI) refers to a disruption or injury to the brain caused by an external force or trauma. It can occur as a result of various incidents such as car accidents, falls, sports-related injuries, assaults, or explosive blasts. TBIs can range in severity from mild to severe, and the effects can be temporary or long-lasting. The brain is a complex organ responsible for controlling our thoughts, emotions, behaviors, and bodily functions. When a TBI occurs, the brain's normal functioning can be significantly disrupted. The specific symptoms and their severity depend on the location and extent of the injury. Mild traumatic brain injury, also known as a concussion, may result in a temporary loss of consciousness, confusion, dizziness, headaches, fatigue, memory problems, difficulty concentrating, mood swings, and sensitivity to light or sound. These symptoms typically resolve within a few weeks with appropriate rest and recovery. Moderate to severe TBIs can cause more pronounced and long-lasting effects. They may result in a longer period of unconsciousness or altered state of consciousness, persistent headaches, repeated vomiting or nausea, seizures, slurred speech, coordination problems, sensory deficits, cognitive impairments, difficulty with attention and memory, mood disorders, depression, anxiety, and personality changes. In some cases, individuals with severe TBIs may enter a coma or experience a persistent vegetative state. The consequences of a TBI can extend beyond the physical and cognitive aspects. They can impact a person's emotional well-being, relationships, and overall quality of life. Rehabilitation and support from healthcare professionals, including neurologists, neuropsychologists, physical therapists, occupational therapists, and speech-language pathologists, are often necessary to help individuals recover and manage their symptoms. It's important to seek immediate medical attention if a TBI is suspected, as early intervention and appropriate care can greatly influence the outcome. Treatment approaches for TBIs may involve rest, medication, physical therapy, cognitive rehabilitation, psychological counseling, and support groups. It's worth noting that each traumatic brain injury is unique, and the effects can vary widely from person to person. Therefore, comprehensive evaluations by medical professionals are essential for an accurate diagnosis and personalized treatment plan.

1. J. KAVITHA LAKSHMI
MPT 2ND YEAR
NEUROLOGY

2.  Traumatic brain injury (TBI) is defined as “an alteration in brain
function, or other evidence of brain pathology, caused by an external
force”.
Prevalence:
 TBI is the leading cause of injury related death and disability.
 Approximately 1.5 to 2 million people admitted to emergency
departments with TBI each year in India.
 Of these, 50,000 people dies as a result of the injury.
 3,00,000 require hospitalization.

3.  Falls 32%
 Motor accident 19%
 Struck against event 18%
 Assualts (10%)
 Men are more frequently affected than women at a ratio of 2:1.
 TBI in infants and children.
 Child abuse (shaken baby syndrome)
 Falls
 Automobile accidents
 Bicycle accident

4. Primary:
Closed injury:
Concussion:
 Concussion is defined as a momentary loss of consciousness and reflexes.
 Symptoms: dizziness, disorientation, blurred vision, difficult concentrating,
alterations in sleep patterns, nausea, headache and loss of balance.
 Patient can have retrograde amnesia and antegrade amnesia.
 With a concussion, there is no structural damage to the brain tissue. It is
due to synapses are distrupted.

5. Contusion:
 Bruising on the surface of the brain is sustained at the time of impact.
 It is due to small blood vessels on the surface are ruptured.
 Coup lesion: contusion that occurs on the same side of the brain as the
impact.
 Countercoup lesion: surface hemorrhages that occur on the opposite
side of the trauma as a result of deceleration.
 Contusion most commonly involve the frontal and temporal lobe.
 Usually multiple and may occur bilaterally.
 This may lead to space occupying hematoma.

7. Diffuse axonal injury:
 Acceleration and deceleration motion that leads to shearing forces to
the white matter of the brain.
 Leads to microscopic and gross damage to the axons in the brain at the
junction of the gray and white matter.
 Involved in the corpus callosum and brain stem.

9. Open injury:
 Penetrating types of wounds such as those received from a gunshot,
knife, or other sharp object.
 Skull can be Either fractured or displaced.
injury to the scalp – laceration or abrasion
Skull fracture:
Simple linear fracture:
 Break in the bone that transverses the full thickness of the skull from
the outer to inner table.
Depressed skull fracture:
 Results from blunt trauma.
 Inner table affected than the outer table

12. Base of skull fracture:
Anterior fossa fracture:
C/f:
 If the nasal discharge contains glucose, the fluid is Csk rather than
mucin – CSF rhinorrheea
 Bruising limited to the orbital margins indicated blood tracing from
behind – bilateral periorbital
 Bruising under conjunctive extending to posterior limits of the sclera
indicates blood tracking from orbital cavity – subconjunctival
haemorrhage hematoma

13. Petrous fracture:
 CSF otorrhoea
 Bruising over the mastoid may take 24 – 48 hours to develop – battle’s
sign.

16. Secondary injury:
 Cerebral edema
 Elevated ICP
 Hypoxemia
 Hypotension
 Ischemia
 hematoma

17. Hematoma:
 Intracranial bleeding
 Types: extradural (epidural) and intradural (subdural) hematoma
Epidural hematoma:
 Between the dura mater and skull.
 Rupture of the middle meningeal artery within the temporal fossa
Subdural hematoma:
 Between the dura and arachnoid mater.
 Rupture of cortical bridging vein.

19. Tonsillar herniation:
 a progressive increase in intracranial pressure due to a supratentorial
hematoma initially produces midline shift.
 Herniation of medial temporal lobe through the tentorial hiatus(lateral
tentorial herniation) causing midbrain compression and damage.
 Bilateral hemispheric swelling result in central tentorial herniation.
 Herniation of the cerebellar tonsils through the foramen magnum
(tonsillar herniaation) cause lower brain stem compression.

21. Blast injury:
 When an explosive device detonates a transient shock wave is
produced, which can cause brain damage.
 Primary: direct effect blast overpressure in brain
 Secondary: shrapnel and other objects being hurled at the individual
 Tertiary: victim is flung backward and strikes an object
 Result in edema, contusion, DAI, hematoma and hemorrhage

23. Neuromuscular impairments:
 UE and LE paresis, impaired coordination, impaired postural control,
abnormal tone and abnormal gait.
 Abnormal , involuntary movements such as tremor and chorea form
and dystonic movements are less common
 Patient presents with impaired somatosensory function depending on
the location of the lesion.
Cognitive impairment:
 Altered level of consciousness are seen.
 Coma, vegetative state and minimally conscious state are disordered
arousal states seen after severe injury

24. Neurobehavioural impairments:
 Low frustration tolerance, agitation, disinhibition, apathy, emotional
lability, mental inflexibility, aggression, impulsivity and irritability
Communication:
 Disorganized and tangential oral or written communication, imprecise
language, word retrieval difficulties and disinhibited socially
impropriate language.
Dysautonomia:
 Increased sympathetic activity results in increased heart rate,
respiratory rate and blood pressure,diaphoresis and hyperthermia
 Paraoxymal sympathetic hyperactivity.

25. Post traumatic seizures:
 Can seen in severe injury
Secondary impairments: (pronlong immobility)
 DVT
 Heterotopic ossification
 Pressure ulcer
 Pneumonia
 Chronic pain
 Contractures
 Decreased endurance
 Muscle atrophy
 Fracture
 Peripheral nerve damage

26. Patients admitted,
Airway
(check for obstruction)
|
Breathing
(check respiratory movements are adequate, if not, ventilate.
Chest X ray – examine chest for possible flail segment or haemo or pneumothorax)
|
Circulation
(check pulse and blood pressure – if hypotensive, replace blood loss with IV fluids
followed by whole blood if Hb < 10g/l)
(CT abdomen – examine abdomen for possible bleeding; if in doubt use ultrasound or
if sufficiently stable)

27. Head / spinal injury
(assess conscious level and focal sign, consider possibility of spinal injury
– CT head and CT/Xray spine)
|
Limb injuries
(X ray – examine limb fracture)
Point to determine:
 Period of loss of consciousness
 Period of post traumatic amnesia
 Period of retrograde amnesia
 Cause and circumstance of the injury
 Presence of headache and vomiting

28. 1. Laceration and bruising
2. Basal skull fracture
3. Conscious level – GCS
4. Pupil response
5. Limb weakness
6. Eye movement
7. Vital signs
8. Cranial nerve lesions

29. CT scan: (hematoma and DAI)

31. X ray:
Lateral view: brow up positioning
Pneumocele and fluid level in sphenoid sinus – basal fracture
Postero – anterior:
Fluid level in frontal sinus
Towne’s view:
Occipital fracture

32. Medical management:
 Anticonvulsant drug – phenytoin
 Elevated intracranial pressure – mannitol
 Antiobiotics
Surgical management:
Epidural hematoma – horseshoe craniotomy flap
Subdural hematoma – burrhole