CEREBRAL CONCUSSION

Background
The most important consideration in any head injury is whether the brain is
injured. Even seemingly minor injury can cause significant brain damage secondary to
obstructed blood flow and decreased tissue perfusion. The brain cannot store oxygen or
glucose to any significant degree. Because the cerebral cells need an uninterrupted
blood supply to obtain these nutrients, irreversible brain damage and cell death occur if
the blood supply is interrupted for even a few minutes. Closed (blunt) brain injury occurs
when the head accelerates and then rapidly decelerates or collides with another object
and brain tissue is damaged but there is no opening through the skull and dura. Open
brain injury occurs when an object penetrates the skull, enters the brain, and damages
the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is
so severe that it opens the scalp, skull, and dura to expose the brain. Injuries to the
brain can be focal or diffuse. Focal injuries include contusions and hematomas.
Concussions and diffuse axonal injuries are the major diffuse injuries.

Definition
A concussion after a head injury is a temporary loss of neurologic function with
no apparent structural damage to the brain. A concussion (also referred to as a mild
TBI) may or may not produce a brief loss of consciousness. The mechanism of injury is
usually blunt trauma from an acceleration-deceleration force, a direct blow, or a blast
injury. If brain tissue in the frontal lobe is affected, the patient may exhibit bizarre

irrational behavior, whereas involvement of the temporal lobe can produce temporary
amnesia or disorientation.
There are three grades of concussion or mild TBI defined by the American
Academy of Neurology when the injury is sport related. A grade 1 concussion has
symptoms of transient confusion, no loss of consciousness, and duration of mental
status abnormalities on examination that resolve in less than 15 minutes. A grade 2
concussion also has symptoms of transient confusion and no loss of consciousness, but
the concussion symptoms or mental status abnormalities on examination last more than
15 minutes. In grade 3 concussion, there is any loss of consciousness lasting from
seconds to minutes.
A mild TBI is often overlooked in the emergency department (ED) because
diagnostic studies may show no apparent structural sign of injury. The duration of
mental status abnormalities is an indicator of the grade of the concussion. The patient is
discharged from the hospital or ED once he or she returns to baseline after the
concussion. Monitoring includes observing the patient for a decrease level of
consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil
response, vomiting, irritability, slurred speech, and numbness or weakness in the arms
or legs. The occurrence of these symptoms is a red flag indicating the need for further
intervention. Recovery may appear complete, but long-term sequelae are possible and
repeat injuries common. Problems at work and at home can result in interpersonal
relationship problems or the loss of employment. The family and patient are instructed
to follow up with the primary provider.

Causes
The brain has the consistency of gelatin. It's cushioned from everyday jolts and
bumps by cerebrospinal fluid inside the skull. A violent blow to the head and neck or
upper body can cause the brain to slide back and forth forcefully against the inner walls
of the skull.
Sudden acceleration or deceleration of the head, resulting from certain events such as a
car crash or being violently shaken, also can cause brain injury.
These injuries affect brain function, usually for a brief period, resulting in signs and
symptoms of concussion.
A brain injury of this sort may lead to bleeding in or around the brain, causing symptoms
such as prolonged drowsiness and confusion that may develop right away or later.
Such bleeding in the brain can be fatal. That's why anyone who experiences a brain
injury needs monitoring in the hours afterward and emergency care if symptoms
worsen.

Statistical Data
Prevalance of Traumatic Brain Injury:
0.2% of population has an acquired brain injury in Australia 1998 (Australias
Health 2004, AIHW)
Prevalance Rate for Traumatic Brain Injury:
Approximately 1 in 500 or 0.20% or 544,000 people in USA

Medical-Surgical Management
Assessment and diagnosis of the extent of injury are accomplished by the initial
physical and neurological examinations. CT and MRI scans are the main neuroimaging

diagnostic tools and are useful in evaluating the brain structure. Positron emission
tomography (PET) is available in some trauma centers for assessing brain function. A
flow chart developed by the Brain Trauma Foundation (2007) for the initial management
of brain injury is presented below.
Any patient with a head injury is presumed to have a cervical spine injury proven
otherwise. The patient is transported from the scene of the injury on a board with the
head and neck maintained in alignment with the axis of the body. A cervical collar
should be applied and maintained until cervical spine x-rays have been obtained and
the absence of cervical spinal cord injury (SCI) documented.
All therapy is directed toward preserving brain homeostasis and preventing
secondary brain injury, which is injury to the brain that occurs after the original traumatic
event (Bader & Littlejohns, 2010). Common causes of secondary injury are cerebral
edema, hypotension, and respiratory depression that may lead to hypoxemia and
electrolyte imbalance. Treatments to prevent secondary injury include stabilization of
cardiovascular and respiratory function to maintain adequate cerebral perfusion, control
of hemorrhage and hypovolemia, and maintenance of optimal blood gas values.

Initial management
Severe head
injury GCS 8 or
ATLS trauma

Emergency
diagnosis or
therapeutic

Endotracheal
intubation
Fluid resuscitation
Ventilation (PaCO2 35
mmHg)
Oxygenation
Sedation
+ Pharmacologic
paralysis (short
Herniation?*
Deterioration?*

+
Hyperventilation

CT scan

Resolution?

Surgical lesion?

Intensive care

Monitor ICP

Treat intracranial
hypertension

Operating room

Diagnostics
A computed tomography (CT) scan is used to diagnose a skull fracture. The ease
with which a diagnosis of skull fracture is made depends on the site of the fracture. If a
fracture is found on CT scan, there is always the question of associated brain injury, and
magnetic resonance imaging (MRI) provides better resolution and clearer pictures of the
injured area (Hickey, 2009).
A blow to the head, neck or upper body can cause a concussion, which may
include symptoms such as a headache, dizziness, nausea or loss of consciousness.
The doctor will evaluate the signs and symptoms, review medical history, and conduct a
neurological examination. Signs and symptoms of a concussion may not appear until
hours or days after the injury.
Tests the doctor may perform or recommend include:
1. Neurological examination
After your doctor asks detailed questions about your injury, he or she may

perform a neurological examination. This evaluation includes checking your:

Vision
Hearing
Strength and sensation
Balance
Coordination
Reflexes
Cognitive testing
Your doctor may conduct several tests to evaluate your thinking (cognitive)
skills during a neurological examination. Testing may evaluate several factors,

including your:
Memory
Concentration
Ability to recall information

2. Imaging tests

Brain imaging may be recommended for some people with symptoms

such as severe headaches, seizures, repeated vomiting or symptoms that are
becoming worse. Brain imaging may determine whether the injury is severe and
has caused bleeding or swelling in your skull.
A cranial computerized tomography (CT) scan is the standard test to
assess the brain right after injury. A CT scan uses a series of X-rays to obtain
cross-sectional images of your skull and brain.
Magnetic resonance imaging may be used to view bleeding in your brain
or to diagnose complications that may occur after a concussion.
An MRI uses powerful magnets and radio waves to produce detailed
images of your brain.

3. Observation
You may need to be hospitalized overnight for observation after a
concussion.
If your doctor agrees that you may be observed at home, someone should
stay with you and check on you for at least 24 hours to ensure your
symptoms aren't worsening. Your caregiver may need to awaken you
regularly to make sure you can awaken normally.