Head Injury Health Article

Skull fracture

A skull fracture is a medical emergency that must be treated promptly to prevent possible brain damage. Such an injury may be obvious if blood or bone fragments are visible, but it's possible for a fracture to have occurred without any apparent damage. A skull fracture should be suspected if there is:

• blood or clear fluid leaking from nose or ears
• unequal pupil size
• bruises or discoloration around the eyes or behind the ears
• swelling or depression of the part of the head

Intracranial hemorrhage

Bleeding (hemorrhage) inside the skull may accompany a head injury and cause additional damage to the brain. A blood clot (hematoma) may occur if a blood vessel between the skull and the brain ruptures; when the blood leaks out and forms a clot, it can press against brain tissue, causing symptoms from a few hours to a few weeks after the injury. If the clot is located between the bones of the skull and the covering of the brain (dura), it is called an epidural hematoma. If the clot is between the dura and the brain tissue itself, the condition is called a subdural hematoma. In other cases, bleeding may occur deeper inside the brain. This condition is called intracerebral hemorrhage or intracerebral contusion (from the word for bruising).

In any case, if the blood flow is not stopped, it can lead to unconsciousness and death. The symptoms of bleeding within the skull include:

• nausea and vomiting
• headache
• loss of consciousness
• unequal pupil size
• lethargy

Postconcussion syndrome

If the head injury is mild, there may be no symptoms other than a slight headache, or there also may be confusion, dizziness, and blurred vision. While the head injury may seem to have been quite mild, in many cases symptoms persist for days or weeks. Up to 60% of patients who sustain a mild brain injury continue to experience a range of symptoms called "postconcussion syndrome," as long as six months or a year after the injury.

The symptoms of postconcussion syndrome can result in a puzzling interplay of behavioral, cognitive, and emotional complaints that can be difficult to diagnose, including:

• headache
• dizziness
• mental confusion
• behavior changes
• memory loss
• cognitive deficits
• depression
• emotional outbursts

Diagnosis

The extent of damage in a severe head injury can be assessed with computed tomography scan (CT scan), magnetic resonance imaging (MRI), positron emission tomography (PET) scans, electroencephalograms (EEG), and routine neurological and neuropsychological evaluations.

Doctors use the Glasgow Coma Scale to evaluate the extent of brain damage based on observing a patient's ability to open his or her eyes, respond verbally, and

respond to stimulation by moving (motor response). Patients can score from three to 15 points on this scale. People who score below eight when they are admitted usually have suffered a severe brain injury and will need rehabilitative therapy as they recover. In general, higher scores on the Glasgow Coma Scale indicate less severe brain injury and a better prognosis for recovery.

Patients with a mild head injury who experience symptoms are advised to seek out the care of a specialist; unless a family physician is thoroughly familiar with medical literature in this newly emerging area, experts warn that there is a good chance that patient complaints after a mild head injury will be downplayed or dismissed. In the case of mild head injury or postconcussion syndrome, CT and MRI scans, electroencephalograms (EEG), and routine neurological evaluations all may be normal because the damage is so subtle. In many cases, these tests can't detect the microscopic damage that occurs when fibers are stretched in a mild, diffuse injury. In this type of injury, the axons lose some of their covering and become less efficient. This mild injury to the white matter reduces the quality of communication between different parts or the brain. A PET scan, which evaluates cerebral blood flow and brain metabolism, may be of help in diagnosing mild head injury, although this is still largely considered to be an experimental procedure.

Patients with continuing symptoms after a mild head injury should call a local chapter of a head-injury foundation that can refer patients to the best nearby expert.