Snapshot A 53-year-old man is brought to the emergency department by his friend after losing consciousness following a bike accident in which he was not wearing a helmet. After falling, the patient hit his head and was difficult to arouse. Medical history is significant for atrial fibrillation currently on metoprolol and apixaban. In the emergency department, the patient appears agitated and had an episode of emesis. A noncontrast CT scan of the head demonstrates an epidural hemoatoma and small intraparenchymal bleeds. Introduction Definition disruption in normal brain function secondary to traumatic injury to the brain Associated conditions cervical spine injury Epidemiology Incidence a leading cause of disability in the United States Etiology Motor vehicle accidents (leading cause) Falls Firearms Contact sports (e.g., boxing and football) Alcohol use Pathogenesis can be divided into primary and secondary brain injury primary brain injury (occurs at the moment of trauma) external mechanical forces are transmitted to the contents within the cranium leading to cerebral contusions hematomas diffuse axonal injury cerebral edema secondary brain injury (occurs immediately after the trauma) cascading molecular injury mechanism after the primary brain injury neuronal excitotoxicity and apoptosis inflammation vascular injury (e.g., vasospasm and microvessel occlusion) Presentation Symptoms/physical exam acute concusstion mild severe confusion amnesia repeat questioning headache nausea/vomiting mild traumatic brain injury headache remains conciouss or has loss of conciousness for a few seconds or minutes behavioral or mood changes trouble with memory or concentration moderate and severe traumatic brain injury similar symptoms as mild traumatic brain injury; however, patients may have worsening headache recurrent nausea and vomiting seizures pupillary changes focal neurological deficits clear liquid coming from the ears and nose (cerebrospinal fluid leak) bruising behind the ears (Battle sign) black eye Imaging Noncontrast head CT indication initial imaging study in patients with recent moderate or severe mechanical brain injury used to determine if there is an intracranial bleed and cranial fractures CT of the cervical spine indication to rule out cervical spine injury with moderate or severe mechanical brain injury Studies Glasgow Coma Scale scores the severity of the traumatic brain injury score of 13-15 mild traumatic brain injury score of 9-12 moderate traumatic brain injury score of 8 or less severe traumatic brain injury Treatment Conservative stabilizing airway, breathing, and circulation indication initial step in management intracranial pressure monitoring indication used in cases of severe traumatic brain injury medical management follows depending on the intracranial pressure other management options depends on the consequences of the traumatic brain injury (e.g., epidural hematoma) rest and primary care follow-up indication for concussions with proper return precautions Complications Skull fractures Intracranial hemorrhages epidural hematoma subdural hematoma subarachnoid hemorrhages intraventricular hemorrhages intracerebral hemorrhages Cerebral herniation Encephalopathy