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Head Injury

A Head Injury Can Be to Difficult Diagnose

Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editors: Melissa Conrad Stöppler, MD

A head injury can be difficult to diagnose

Minor head injuries are a routine occurrence. From toddlers falling against tables, kids bumping heads playing ball, to an elderly person falling down; people often lead with their heads when they move about. Usually, a few stars are seen, a headache happens, and all is well. Sometimes it isn't so clear. The person may be knocked out for a few seconds, may vomit, and perhaps may have some loss of memory but by the time the doctor visits the bedside, everything is back to normal. The diagnosis of a concussion is made.

But now what? What do you do with somebody who acts and appears normal, even though there was a history of a head injury? Who will have bleeding in their brain and who won't? Who needs a CT scan and who just needs to go home?

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Head Injury Overview

Head injury is a general term used to describe any trauma to the head, and most specifically to the brain itself.

Skull fracture: A skull fracture is a break in the bone surrounding the brain and other structures within the skull.

Linear skull fracture: A common injury, especially in children. A linear skull fracture is a simple break in the skull that follows a relatively straight line. It can occur after seemingly minor head injuries (falls, blows such as being struck by a rock, stick, or other object; or from motor vehicle accidents). A linear skull fracture is not a serious injury unless there is an additional injury to the brain itself.
Depressed skull fractures: These are common after forceful impact by blunt objects-most commonly, hammers, rocks, or other heavy but fairly small objects. These injuries cause "dents" in the skull bone. If the depth of a depressed fracture is at least equal to the thickness of the surrounding skull bone (about 1/4-1/2 inch), surgery is often required to elevate the bony pieces and to inspect the brain for evidence of injury. Minimally depressed fractures are less than the thickness of the bone. Other fractures are not depressed at all. They usually do not require surgical treatment unless other injuries are noted.
Basilar skull fracture: A fracture of the bones that form the base (floor) of the skull and results from severe blunt head trauma of significant force. A basilar skull fracture commonly connects to the sinus cavities. This connection may allow fluid or air entry into the inside of the skull and may cause infection. Surgery is usually not necessary unless other injuries are also involved.

Intracranial (inside the skull) hemorrhage (bleeding)

Subdural hematoma: Bleeding between the brain tissue and the dura mater (a tough fibrous layer of tissue between the brain and skull) is called a subdural hematoma. The stretching and tearing of "bridging veins" between the brain and dura mater causes this type of bleeding. A subdural hematoma may be acute, developing suddenly after the injury, or chronic, slowly accumulating after injury. Chronic subdural hematoma is more common in the elderly whose bridging veins are often brittle and stretched and can more easily begin to slowly bleed after minor injuries. Subdural hematomas are potentially serious and may require surgery.
Epidural hematoma: The skull is made up of a variety of bones; the dura, the thick membrane that wraps around the brain, attaches at the suture lines where the bones come together. If bleeding occurs in the enclosed space between the dura and the bone, and a hematoma (blood clot) forms, there is nowhere for it to accumulate and pressure within the epidural space can build quickly. The increasing pressure pushes the hematoma against the brain tissue and may cause significant damage.

Tiny epidural hematomas potentially may be observed without surgery, but often surgery is indicated to removed the hematoma and relieve the pressure on the brain. The earlier the operation, the better, because the death rate increases if the patient is in a coma at the time of operation.

Subarachnoid hemorrhage: Subarachnoid hemorrhage can be caused by trauma and often does not require surgery. Blood accumulates in the space beneath the arachnoid layer that surrounds the brain. While this can irritate the brain and cause symptoms of headache, vomiting, and stiff neck, treatment may be watchful waiting without surgery unless symptoms worsen.
Intraparenchymal hemorrhage/cerebral contusion: These terms describe bleeding into the brain tissue itself. A contusion is like a bruise to the brain tissue and usually requires no special intervention, much like a concussion. Most doctors admit people with cerebral (brain) contusion to the hospital for observation since there may be rare complications such as brain swelling. An intraparenchymal hemorrhage is a pool of blood within the brain tissue. Minor bleeding may stop without any treatment and cause no serious problems. More serious or large bleeds usually require surgery.

Closed head injuries: This broad term describes any injury to the brain or structures within the skull that is not caused by a penetrating injury (such as a gunshot wound or stab wound). They range from very minor to potentially fatal injuries.

Picture of the areas of the brain subject to injury