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TimoKoivisto
TeemuLuoto

Brain Contusion

Essentials

  • Brain contusion is one of the most common structural brain injuries that can be detected by imaging. A brain contusion can be found
    • in a CT scan of the head in about 10% of patients with brain injury
    • in almost half of the patients with moderate to severe brain injury. The majority of contusions are located in the frontal or temporal lobes.
  • Brain contusion should be suspected if a patient with head injury has
    • decreased level of consciousness (GCS < 15, see Brain Injury and Skull Fracture)
    • neurological deficit symptoms (hemiparesis, papillary asymmetry, aphasia) or epileptic seizures.
  • Acute diagnosis of a brain contusion is based on a CT scan of the head.
  • A CT scan is performed immediately on every unconscious patient and on emergency basis if brain contusion is suspected.
  • The level of consciousness and the neurological condition of a patient with brain contusion are monitored in a hospital.
  • A neurosurgeon is consulted concerning the treatment of brain contusion injuries.
  • Patients with brain contusion and disturbance of consciousness are initially treated in an intensive care unit.

Diagnosis

  • The diagnosis of brain contusion is clinical and radiological.
  • The severity of the brain contusion correlates with the level of consciousness and the duration of unconsciousness.
  • Brain contusion is often the only injury; however, about 10% have multiple injuries.
    • It is important to exclude cervical spine injuries immediately. Treat the patient as if he/she had a cervical spine injury until results from imaging studies (CT or MRI) are available.
  • Regular determination of the level of consciousness An Unconscious Patient is the cornerstone in monitoring the patient.
  • The CT scan shows the location of brain contusions, possible larger pooling of blood and the condition of the brain ventricles and gives hints of possible intracranial pressure elevation.
  • An MRI study reveals reliably even minor contusions and haematomas. In young and working-age patients, MRI should be included in the early stage investigations.

Treatment of the acute phase

  • An unconscious patient or a patient with decreased level of consciousness and a brain contusion is treated in the intensive care unit.
  • The measurement of the intracranial pressure Increased Intracranial Pressure and prevention or treatment of increasing pressure are procedures that may be required in patients with brain contusion.
    • Postural therapy: the upper trunk of the patient 30° elevated
    • Hypoventilation should be avoided . If the patient is intubated, controlled normoventilation can be started already during transportation.
    • Pressure can be controlled for a short time with mannitol or with hypertonic saline solution. Glucocorticoids are not shown to be beneficial.
    • Prophylactic antiepileptic medication (e.g. phenytoin or levetiracetam) should be used in the short term (approximately for one week) in brain contusions.
  • The additional information provided by repeated CT scans is useful in the detection of late haematomas and in monitoring the growth of the brain contusion lesions.
  • Factors predicting the growth of a brain contusion include, among others, low level of consciousness, hypertension, smoking, coagulopathy and large size of the contusion in the initial scan.
  • Due to lack of intracranial space, surgical treatment of brain contusion may be required. In extreme cases, an extensive decompressive craniectomy may be performed to reduce intracranial pressure.

Further treatment

  • The phase of acutely increasing intracranial pressure is usually over in 4-5 days. After this, even an unconscious patient with secured airways (tracheostomy as necessary) can be treated on a ward.
  • Over the next 3-4 weeks of follow-up, the prognosis and the need for further treatment and rehabilitation usually become clear.
    • Mild contusion injuries do not usually prevent normal recovery and return to work.
    • More severe contusion injuries are likely to result in extensive cognitive changes and personality changes that require a neurological rehabilitation programme and further attention. In these cases, MRI of the head performed both in the initial and in the late phase gives valuable additional information about the extent of the injury.
    • The prognosis for neurological deficiency symptoms, e.g. paralyses, is basically good but rehabilitation should be continued for a sufficient time.
    • The incidence of epilepsy developing within one year after the injury is under 5%, but intracerebral haematoma increases the incidence to up to 30%. After 10 years half of the patients are free of attacks.

    References

    • Carney N, Totten AM, O'Reilly C ym. Guidelines for the management of severe traumatic brain injury. Fourth Edition. Neurosurgery 2017;80(1):6-15. [PubMed]
    • Isokuortti H, Iverson GL, Silverberg ND ym. Characterizing the type and location of intracranial abnormalities in mild traumatic brain injury. J Neurosurg 2018;():1-10. [PubMed]
    • Brandstack N. Detection of pathologic changes following traumatic brain injury using magnetic resonance imaging [Thesis]. Annales Universitatis Turkuensis D 1061, 2013 http://urn.fi/URN:ISBN:978-951-29-5340-0
    • Brain Trauma Foundation. Guidelines for the management of severe traumatic brain injury. 3rd edition. Journal of neurotrauma; vol. 24, Supplement 1, 2007 http://www.braintrauma.org/uploads/11/14/Guidelines_Management_2007w_bookmarks_2.pdf.
    • Yang Y, Zheng F, Xu X et al. Levetiracetam Versus Phenytoin for Seizure Prophylaxis Following Traumatic Brain Injury: A Systematic Review and Meta-Analysis. CNS Drugs 2016;30(8):677-88. [PubMed]
    • Alahmadi H, Vachhrajani S, Cusimano MD. The natural history of brain contusion: an analysis of radiological and clinical progression. J Neurosurg 2010;112(5):1139-45. [PubMed]
    • Danish SF, Barone D, Lega BC et al. Quality of life after hemicraniectomy for traumatic brain injury in adults. A review of the literature. Neurosurg Focus 2009;26(6):E2. [PubMed]
    • Adatia K, Newcombe VFJ, Menon DK. Contusion Progression Following Traumatic Brain Injury: A Review of Clinical and Radiological Predictors, and Influence on Outcome. Neurocrit Care 2020;():. [PubMed]