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Traumatic Brain Injury (TBI)
What are traumatic brain injuries?
Traumatic brain injuries (TBIs) are injuries sustained to the brain by a mechanical force either directly to the head or to the body that is then transmitted to the head. The injury can be open, meaning a foreign object has caused an open wound, or closed, in which case the injury is caused by a blunt force to the head that does not enter the skull. Most TBIs are closed injuries. Traumatic brain injuries result in both primary and secondary injury. Primary injury occurs due to mechanical forces from the initial trauma and may include bleeding or bruising (contusion) in the brain. Secondary injury follows and results from the body’s reaction to the initial (primary) injury. The secondary injury may include swelling, inflammation and other changes that may contribute to neurological damage.
What Causes a Traumatic Brain Injury?
There are many causes of a traumatic brain injury. Some common incidents that can cause TBIs in children include:
- Motor vehicle accidents
- Bike accidents
- Sports/recreation-related injuries
- Falls
- Abuse
Prevalence of traumatic brain injuries in children
TBIs have become more common in children. According to the Center for Disease Control (CDC):
- Children ages 0-17 years old accounted for approximately 8.6% of all TBI-related hospitalizations in 2016 and 7.8% in 2017.
- The most common injury for TBI-related hospitalizations among children were falls and motor vehicle crashes in 2016 and 2017.
- In 2018, there were 16,480 TBI-related hospitalizations among children.
- In 2019, there were 2,476 TBI-related deaths among children.
Types of traumatic brain injuries
Different types of traumatic brain injuries that commonly occur in children include:
- Hematoma/Hemorrhage: A hematoma or hemorrhage is a collection of blood and can occur in the brain. Brain hemorrhages may be epidural, subdural, subarachnoid or intraparenchymal. Epidural hematomas occur between the covering of the brain (dura mater) and the inside of the skull. Subdural hematomas occur between the dura mater and the surface of the brain (arachnoid layer). Subarachnoid hemorrhage occurs between the brain surface (arachnoid layer) and brain tissue. Intraparenchymal hemorrhage occurs within the brain tissue itself. Sometimes brain hemorrhages require surgical treatments.
- Contusion: A contusion is bruising on the brain tissue and causes bleeding and swelling inside the brain where the injury occurred. Contusions are usually at the front of the brain but can occur in other areas.
- Concussion: A concussion is a mild traumatic brain injury that typically results in functional changes in the brain without any structural damage visible on standard imaging studies. Learn more about concussions in children.
- Diffuse Axonal Injury (DAI): When the brain rapidly shifts in the skull, there can be shearing of the nerve fibers as the brain shifts and rotates inside the skull. When axons are damaged, brain cells might not be able to communicate, potentially causing impaired function.
- Ischemia: Sometimes after a traumatic injury, there can be disruption of blood flow to areas of the brain, which can lead inadequate oxygen supply and death of brain tissue.
- Skull Fractures: A skull fracture occurs when there is a crack in one or more of the bones that comprise the skull. Skull fractures can cause damage to the brain in some cases. There are four major types of skull fractures: linear, depressed, diastatic and basilar. Fractures at the base of the skull, like basilar fractures, can be dangerous, as they can cause leaking of spinal fluid and injury to nerves.
Symptoms of Traumatic Brain Injury in Children
Symptoms of traumatic brain injuries vary, largely depending on injury severity. They can appear immediately, days or even weeks after the trauma. Children with TBIs can struggle to communicate the symptoms they are feeling, so it is important for you to observe children closely if they have incurred an injury to the head.
Mild
Physical:
- Loss of consciousness
- Seizure
- Headache
- Nausea or vomiting
- Vision change
- Light sensitivity
- Noise sensivity
- Dizziness
- Balance Problems
- Persistent crying
- Local bruising or swelling
Mood:
- Irritability
- Nervousness
- Sadness or depression
Cognitive:
- Memory problems
- Problems concentrating or focusing
- Slow to process or respond to information
Sleep:
- Drowsiness
- Fatigue
- Sleeping more than usual
- Difficulty sleeping
Moderate to Severe
Physical:
- Loss of consciousness
- Persistent or worsening headache
- Repeated nausea or vomiting
- Convulsions or seizures
- Dilation of one or both pupils
- Clear fluids draining from nose or ears
- Trouble staying awake
- Weakness or numbness in fingers and toes
- Loss of coordination
- Persistent crying
- Trouble walking
- Pale color of skin
- Bruising around the eyes or behind the ears
Cognitive:
- Profound confusion
- Agitation
- Combativeness or other unusual behavior
- Slurred speech or changes in speech
- Loss of memory
When to See a Doctor for a Traumatic Brain Injury
Your child should always see a doctor if they have received an injury to the head that concerns you or causes behavioral changes. Despite the severity of the injury, all injuries can be serious and need to be evaluated by a doctor.
When is it an emergency?
If your child experiences any injury with loss of consciousness, seizure or severe headache with vomiting, or severe neck pain, seek emergency medical care at your closest emergency department or call 9-1-1.
How is a Traumatic Brain Injury Diagnosed?
A traumatic brain injury in children is diagnosed through a history and physical examination by a doctor. Doctors examine your child and ask about their symptoms and the cause of the injury. Depending on the severity and symptoms, the below tests may be conducted:
- CT scan: This is an excellent test utilizing highly detailed x-rays to detect blood and fractures in the skull.
- MRI: As this test takes longer to conduct, it may not be done until after the patient is stable. Once stabilized, MRI’s can be used to get a more detailed picture of the brain and assess subtler signs of brain injury.
- Neurological exams: This can include examining the pupils, corneal reflexes, mental status, motor function, sensory functions, reflexes, coordination and balance.
- Glasgow Coma Scale (GCS): This is a 15-point test that helps to assess the initial severity by checking the patient’s ability to follow directions with their eyes and body. The higher the score, the less severe the injury.
- X-ray: X-rays can be used to evaluate skull fractures.
- Electroencephalogram (EEG): This is a test that looks at electrical activity in the brain and helps identify seizures and other types of brain dysfunction.
As most initial brain damage cannot be reversed, doctors focus on trying to prevent further brain injury.
Treatment for Traumatic Brain Injuries
Treatment for a traumatic brain injury will depend on your child’s symptoms, type of injury, and severity. Mild TBI cases usually require no treatment beyond brief rest and pain management. This can mean limiting physical and cognitive activities until the doctor advises it safe to do so.
For moderate to severe injuries, surgery is a common treatment. Surgical procedures can be done to treat bleeding or swelling in the brain, reduce pressure placed on the brain and/or repair skull fractures. After surgery, your child will be in the intensive care unit (ICU) for observation. Sometimes patients do not need surgery immediately and will be taken to the ICU for observation and monitoring. Learn more about the Pediatric Intensive Care Unit (PICU) at CHOC.
Rehabilitation for traumatic brain injuries
Depending on the severity of injury and symptoms, patients may benefit from rehabilitation services. Rehabilitation can begin in the hospital and continue in an inpatient unit or through outpatient services. For more severe trauma patients with a slower recovery, constant monitoring is needed, so they may remain in the hospital longer for rehabilitation. Children with moderate injuries or whose injuries have significantly improved can typically be transferred to outpatient services.
The type and length of rehabilitation are different for everyone. Services can include physical, occupational or speech therapy. Children with more extreme brain trauma may need to relearn basic skills like walking, talking or feeding themselves. The goal of rehabilitation is for patients to regain and receive maximum function of their brain.
Learn more about CHOC’s rehabilitation services.
Outcomes/prognosis after traumatic brain injuries
Recovery from a TBI is individualized and depends on many circumstances. Mild TBI cases are typically expected to improve and return to normal function somewhat quickly. Some children and adolescents experience symptoms like headaches and dizziness initially, but these symptoms gradually improve over time in most cases.
Children with moderate or severe TBIs are more likely to experience moderate to severe disabilities, which may be permanent in some cases.
Traumatic brain injuries can affect many different body functions. These can occur immediately or soon after trauma.
Altered Consciousness
Changes in consciousness can be brief, prolonged or permanent. Disorders of consciousness that may occur after TBI include:
- Coma
- Vegetative or Unresponsive Wakefulness state
- Minimally Conscious state
Physical
These symptoms may also vary in duration and can last from days to months or longer after an injury. Some symptoms may only develop months after an injury.
- Hydrocephalus (fluid buildup within the brain)
- Seizures
- Blood vessel damage
- Headaches
- Vertigo/dizziness
- Nausea/vomiting
- Balance problems
- Vision problems
- Hearing problems
- Weakness or changes in sensation
- Tight/stiff muscles (spasticity)
Injuries at the base of the skull can cause nerve damage to the cranial nerves. Cranial nerve damage can result in:
- Paralysis of facial muscles
- Loss of feeling on or both sides of the face
- Loss of smell, taste, vision or hearing
- Dizziness
- Problems with eye movements
- Ringing in the ear
Cognitive
It is common for people with TBIs to experience trouble in cognitive functioning such as:
- Memory
- Learning
- Reasoning
- Judgment
- Concentration
- Attention
- Problem-solving
- Multitasking
- Planning
Communication
Communication problems can cause frustration and can include:
- Difficulty speaking or writing
- Trouble understanding speech
- Struggling to follow and participate in conversations
- Problems with changing tones to express emotion
- Trouble organizing thoughts
Behavioral
Behavioral changes are common and can include:
- Verbal or physical outbursts
- Social difficulties
- Lack of awareness
- Disinhibition
Emotional
Along with the other changes, traumatic brain injuries can cause many emotional struggles:
- Depression
- Anxiety
- Mood swings
- Irritability
- Difficulty sleeping
- Anger
Preventing Traumatic Brain Injuries
While not all head injuries can be avoided, there are common precautions parents can follow to help prevent the most common causes of brain injuries in children.
- Always have your child buckled in a safety seat that is appropriate for their size.
- Never drive under the influence of alcohol or drugs.
- Always have your child wear a helmet and appropriate head protection for outdoor activities.
- Pay attention to your surroundings.
- Installing window guards and safety gates to help prevent falls.
For more injury prevention tips, read our safety guides.
Frequently Asked Questions About TBIs
- There is severe head bleeding
- A child cannot stay awake
- A child stops breathing
- A child is confused or unconscious
- A child has a seizure after hitting his/her head
