Head Injuries: What to Watch for Afterward
What are the main causes of head injuries?
A serious head injury is most likely to happen to someone who is in a car wreck and isn't wearing a seat belt. Other major causes of head injuries include bicycle or motorcycle wrecks, falls from windows (especially among children who live in the city) and falls around the house (especially among toddlers and the elderly).
Are head injuries serious?
They can be. Bleeding, tearing of tissues and brain swelling can occur when the brain moves inside the skull at the time of an impact. But most people recover from head injuries and have no lasting effects. See the box below for a list of types of head injuries.The World Health Organization task force on MTBI recommends that the major focus of managing the acute injury should be identifying clinically significant intracranial injuries. The prevalence of intracranial abnormalities in MTBI is approximately 5%.3
Clinical risk factors for significant intracranial lesions that may require neurologic intervention include age older than 60 years, vomiting, headache, seizure, anterograde amnesia, or a dangerous mechanism of injury, such as being hit by a car, ejected from a motor vehicle, or falling from a height of more than 3 ft or 5 steps. Other indicators of risk for clinically significant lesions include a GCS score less than 15, drug or alcohol intoxication, skull fracture, or trauma above the clavicles. CT scan is warranted for any of these factors.4 Thus, the 70-year-old nursing home patient described in the first case should undergo a brain CT scan even though the physical exam is normal. If the CT scan reveals no relevant abnormalities or if the patient has no identifiable risk factors and a GCS score of 15, the patient can be discharged to observation and follow-up. A patient whose GCS score is 13 or 14 or whose CT scan demonstrates abnormalities should be admitted to the hospital.
FOLLOW-UP CARE
Patients with MTBI may have persistent headache, dizziness, compromised cognitive function, depression, or chronic pain. Although most patients with MTBI recover fully, short-term modifications in work, school, home, or sports activities may be needed. Follow-up care of a patient with MTBI should begin with a history that includes the mechanism of injury, duration of loss of consciousness and PTA, GCS score, history of seizure, vomiting, headache, evidence of skull fracture, and results of any tests performed to date. The exam includes the baseline neurologic, cognitive, and emotional status. Next, the patient's ability to return to work, sports, and daily activities is assessed, and any necessary modifications in these areas are discussed. It is important to identify risk factors such as alcohol use, depression, or a chronic medical condition so these issues can be addressed to mitigate their effect on full recovery.7 A goal of follow-up care is to educate the patient and establish realistic expectations for recovery.
The American Academy of Neurology guidelines on concussion in sports recommend that athletes return to play only when they are free of symptoms (see "Managing head-injured athletes during competition"). This minimizes the cumulative cognitive and neurologic effects of concussion and also minimizes the possibility of a second injury, which can be a precursor to the potentially fatal second-impact syndrome, characterized by a rapid rise in intracranial pressure, potentially leading to herniation, coma, and death.
Although patients with a mild injury typically recover completely in a few days, more significant MTBI, such as that associated with a longer period of PTA, may cause cognitive function impairment that persists for weeks or months and that requires adjustments or modifications at work, such as a restriction on operating machinery until cognitive symptoms resolve.
POSTCONCUSSIVE SYNDROME
The term postconcussive syndrome is often used to describe a condition in which symptoms of a TBI persist beyond the initial acute phase of injury and generally resolve within 3 to 12 months. Some experts have suggested that factors such as life stressors, old age, previous health status, and the possibility of compensation and litigation can delay resolution of symptoms.7 Thus, a doctor who examines a patient who has postconcussive symptoms should be mindful of the possibility of secondary causes of the symptoms.
Headache The most common symptom of postconcussive syndrome is headache and can be caused by musculoskeletal problems, occipital neuralgia, post-traumatic migraine, radiculopathy, and inner ear conditions. Rebound headaches may occur in MTBI patients who use OTC analgesics frequently. After secondary causes are ruled out, agents such as beta-blockers, tricyclic antidepressants, calcium channel blockers, anticonvulsive drugs, and alternative treatments can be used as appropriate.
Dizziness Diagnostic testing to evaluate dizziness that remains unresolved after several weeks includes audiology evaluation, brain imaging, and electronystagmography. A referral to a neuro-otolaryngologist may be necessary for a patient with persistent post-traumatic dizziness.
Cognitive dysfunction Persistent problems with memory, concentration, attention, and information processing may require neuropsychological testing and rehabilitation with either restorative or compensatory cognitive retraining. Compensatory rehabilitation helps the patient adapt to cognitive problems employing memory books, or personal digital assistants. Some patients with MTBI may require vocational and occupational training.
Anxiety and depression are sometimes evident in patients recovering from an MTBI. The symptoms experienced by the 38-year-old woman described in the fourth case report-poor concentration, disordered sleep, and irritability-are seen in patients with depression as well as after a patient has had a head injury. Ask the patient if she has had depression or a mood disorder or if she has had a brain injury (including any loss of consciousness or PTA) and then review systems for other diagnoses such as anemia and thyroid problems. This patient reports no history of depression but does report a fall 2 months earlier. Although she was alone at the time of the fall and does not recall losing consciousness or experiencing PTA, she does recall feeling dazed at the time.
Although the patient's symptoms of headache and dazed feeling resolved quickly, she feels inefficient at work, leading to disordered sleep and anxiety about deadlines and her job performance. This patient's history supports a diagnosis of MTBI, and, although any cognitive dysfunction she had at the time of injury was probably mild, her job is stressing her cognitive functioning. Depression may also contribute to her problems. This patient may benefit from making lists, prioritizing tasks, and allowing extra time to complete tasks.
Pain Neck pain and stiffness as well as other chronic pain also can complicate the postconcussive period. In the absence of suspected radiculopathy or spinal cord involvement, treatment for pain includes anti-inflammatory agents, physical therapy, antidepressants, muscle relaxants, analgesic injections, or alternative therapies. Managing head-injured athletes during competition
Within the context of measuring the severity of these injuries on the field of play and allowing the athlete to return to the contest, the American Academy of Neurology practice parameter on the management of mild traumatic brain injury (MTBI)-sometimes referred to as concussion-in sports provides guidelines for the care of athletes by on-site medical personnel and by primary care doctors providing their follow-up care.1
Grade I concussion involves transient confusion but no loss of consciousness, and symptoms, such as inattention, poor concentration, and inability to sequence tasks, last less than 15 minutes. The player should be removed from the competition, examined immediately, and then reexamined every 5 minutes to monitor for the development of mental status abnormalities or postconcussive symptoms both at rest and with exertion. The athlete may return to play if symptoms resolve within 15 minutes. An athlete who sustains 2 grade I concussions on the same day should not return to play until he has been without symptoms for at least 1 week.
Grade II concussion also involves no loss of consciousness, but symptoms last more than 15 minutes. The player should be removed from the contest and not return to play on that day. The patient should be examined frequently the same day for signs of evolving intracranial pathology and again the next day. After the patient has been asymptomatic for at least 1 week (or 2 weeks if the patient has had a prior grade 2 concussion) both at rest and with exertion, a neurologic examination should be performed to clear the athlete for return to play. Persistent symptoms after 1 week warrant imaging studies.
Grade III concussion is characterized by loss of consciousness. An athlete who remains unconscious or who has worrisome examination findings should receive cervical spine immobilization and be transported from the field to the nearest emergency department by ambulance. A thorough neurologic evaluation should be performed emergently, including appropriate imaging studies. The patient can return to play after being asymptomatic for at least 1 week if unconsciousness lasted only seconds and after 2 weeks if unconsciousness lasted minutes or longer. Athletes who sustain a second grade III concussion should be asymptomatic for 1 month before returning to play. Athletes with concussions whose imaging studies demonstrate brain swelling or other intracranial pathology, such as contusion, should not be allowed to play for the remainder of the season. Although he did not lose consciousness, the 15-year-old football player's prolonged symptoms described in case 5 suggests a grade II concussion that should prevent him from returning to play for the rest of the day. In addition to frequent examinations during the game, the patient should be reexamined the next day and cleared for return to play only after being asymptomatic for 1 week.