Traumatic brain injury

A craniocerebral trauma occurs in the course of an external force, and as a consequence brings an injury to the brain.

The function of the posterior skull is to protect the brain from injury by enclosing it. At its base, the skull connects to the cervical spine. The anterior facial skull supports the eye socket, as well as the upper and lower jaws.

A majority of skull fractures can cause brain injuries as a result. On the other hand, concussions or brain contusions can also occur without consequences. Nevertheless, severe brain injuries can also lead to bleeding into the underlying brain tissue or brain contusions.

The most severe effects of traumatic brain injury involve bleeding into the brain. These can occur immediately after the injury, or they can be delayed for up to 48 hours. For this reason, patients with head injuries should be monitored and treated as inpatients.

Conjecture suggests that 332 people in Germany are victims of a traumatic brain injury each year. For the most part, these injuries are not too serious, yet many sufferers succumb to the severe consequences. Especially in early adulthood, craniocerebral injuries are among the most frequent causes of death.

The cause of a traumatic brain injury is an external force, such as a blow or a fall. The bones of the skull may break and consequently the brain may be injured. In this case, one speaks in the medical sense of a craniocerebral trauma.

In addition to headaches, a number of other symptoms may indicate a traumatic brain injury:

• ...ranging from drowsiness to unconsciousness...
• Disorientation
• Confusion
• Emotional disturbances such as aggression
• Nausea and vomiting
• Visual disturbances
• severe spinning dizziness
• Epileptic seizures

Doctors divide traumatic brain injury (SHT) into three stages:

• Mild traumatic brain injury (SHT1): brief loss of consciousness (seconds to a maximum of 30 minutes, memory loss for the time after the event lasting less than 60 seconds), late effects are unlikely
• Moderate traumatic brain injury (SHT2): unconsciousness for more than 30 minutes, late effects are also rare here.
• Severe traumatic brain injury (SHT3): prolonged unconsciousness, late effects are to be expected.

Over 90 percent of craniocerebral injuries are of the mild form (SHT1). In addition, the score on the Glasgow Coma Scale (GCS) determines the severity of the traumatic brain injury. In this rating, the affected person receives a certain number of points for certain reactions of which he or she is capable during the orienting examination at the scene of the accident. Typical reactions include:

• Eye opening
• Reaction to pain stimuli
• Verbal utterances

At the end, the points are added up. The best score that can be achieved is 15, the worst 3. Mild traumatic brain injuries usually have a GCS score of 13 to 15 (moderate: 9 to 12, severe: 5 to 8). In the meantime, a fourth stage of craniocerebral injuries is also distinguished, which describes the most severe cases (GCS- value 3-4).

In these patients, who are usually unconscious, the pupillary reflexes are absent at the beginning or they are significantly slower. In general, these patients can be assumed to have significant damage to the brain stem, which is responsible for controlling breathing and circulation, among other things.

Patients with craniocerebral trauma must receive immediate neurological and surgical clarification. Suitable institutions for this are the emergency departments of hospitals.

If the suspicion of a craniocerebral trauma is confirmed, it is the doctor's task to find out what circumstances caused the accident. In the best case, witnesses to the accident or paramedics are interviewed. The aim is to reconstruct the course of the accident as realistically as possible in order to have an idea of how long the injured person was unconscious.

The extent of larger bone fractures of the skull, especially if the individual fragments are displaced against each other, can be determined well on the basis of an X-ray image. However, the primary focus of any craniocerebral trauma is examination by computed tomography (CT), as this is the only way to rule out possible brain damage. CT is considered to be the most reliable examination immediately after the accident, as it is the best way to detect brain bleeding, bruising and other injuries. However, if the CT does not show any abnormalities but the accident-related symptoms persist, a magnetic resonance imaging (MRI) scan will be ordered.

In addition to these examinations, the doctor will also take a blood sample to determine the amount of blood platelets (thrombocytes) and other clotting parameters.

If there is only a slight craniocerebral trauma, an inpatient stay may not be necessary under certain circumstances. This is the case if, for example, there is only a brief loss of consciousness (less than 15 minutes) and memory loss of less than 30 minutes immediately after the accident. However, the prerequisites for this outpatient treatment are that the CT is unremarkable and the patient has not shown any symptoms since the accident.

If the patient has suffered a more severe traumatic brain injury, they should be under inpatient observation for at least 24 hours. This is especially true for those patients who are also taking a blood-thinning medication (anticoagulation), as they are at increased risk for delayed cerebral hemorrhage.

Rarely, surgical treatment by a neurosurgeon is required. This is only the case if there is major bleeding to prevent rebleeding or to relieve the surrounding brain tissue from the pressure of the blood.

Further treatment of the traumatic brain injury depends on the damage done to the brain. Ordinary skull fractures do not require any special further treatment. Severe brain injuries, on the other hand, may require admission to a special clinic or early rehabilitation facility.

If the patient suffers only a minor traumatic brain injury, the probability of complications such as wound healing disorders, infections or secondary bleeding is very low. The mortality rate is also very low in this case.

In the case of a severe traumatic brain injury, however, permanent damage cannot be ruled out. These can be both mild disorders of personality or memory, as well as severe deficits, such as a coma (apallic syndrome).