Evaluation of traumatic brain injury, acute

Diseases

Summary

Definitions

Traumatic brain injury (TBI) is an acquired disruption of the normal function or structure of the brain caused by a head impact or external force.[1][2] Blunt trauma, penetrating injuries, and blast injuries may cause TBI. However, not all impacts to the head cause TBI. Similar impacts in different people can lead to different injuries based on individual patient factors.

TBI is extremely heterogeneous, with short and long-term outcomes affected by the specific intracranial injury, concomitant extracranial injury, age, and pre-existing comorbidities.

Classification

TBI can be classified in numerous ways, including type, severity, location, mechanism of injury, and physiological response to injury.

Most classification systems are based on patient symptomatology, clinical exam or diagnostic findings during the early stabilization phase, which does not account for the evolving TBI process.

Both the Centers for Disease Control and Prevention and the World Health Organization agree that mild TBI is due to a blunt or mechanical force that results in some type of transient confusion, disorientation, or loss of consciousness lasting not more than 30 minutes; is possibly associated with transient neurobehavioral deficits; and has a Glasgow Coma Scale (GCS) score no lower than 13.[3] CDC: heads up This definition does not, however, identify all patients with significant intracranial injury as, although rare, some patients may present initially with none of these TBI symptoms.[4] These "missed" patients become symptomatic over time, and so it has been suggested that classification based on repeated risk assessment over time would allow for the many variables that affect outcome.[5]

Classification by clinical severity

TBI can be classified as mild, moderate, or severe, based on neurobehavioral deficits and advanced imaging findings after the injury. The term "concussion" is often used interchangeably with mild TBI.

The GCS is widely used to assess objectively the level of consciousness, and can range from 3 (completely unresponsive) to 15 (responsive). The GCS has been used extensively to classify TBI into levels of severity and prognosis.[6] [7] In the setting of TBI, there is a well-documented inverse relationship between the GCS and the incidence of positive findings on computed tomography (CT); the rate of intracranial injury and need for neurosurgical intervention doubles when the GCS drops from 15 to 14.[8] [9]

Mild TBI: GCS 13-15; mortality 0.1%
Moderate TBI: GCS 9-12; mortality 10%
Severe TBI: GCS <9; mortality 40%.

There is continued controversy about including a GCS of 13 in the category of mild TBI, due to the higher incidence of intracranial injury in these patients compared with those with a GCS of 14 or 15.[10] [11] [12] Clinical guidelines in Australia recognize the increased morbidity associated with a GCS of 13, and limit the classification of mild TBI to those patients with a GCS of 14 or 15.[13]

The Mayo classification system for TBI classifies patients with TBI into definite, probable, and possible, based on the patient's clinical and CT findings.[14]

Classification by broad etiology

May be blunt, penetrating, or blast-related.

Blunt TBI: occurs when external mechanical force leads to rapid acceleration or deceleration with brain impact. Blunt TBI is typically found in the setting of motor vehicle-related injury, falls, crush injuries, or physical altercations.
Penetrating TBI: occurs when an object pierces the skull and breaches the dura mater, seen commonly in gunshot and stab wounds.
Blast TBI: commonly occurs after bombings and warfare, due to a combination of contact and inertial forces, overpressure, and acoustic waves.[15]

Classification by area of involvement

TBI can be classified by area of the brain involved, as in diffuse or focal, although the two types frequently coexist.[16]

Diffuse brain injury includes diffuse axonal injury, hypoxic brain injury, diffuse cerebral edema, or diffuse vascular injury.
Focal injury includes specific lesions such as contusions, intracranial hematomas, infarctions, axonal tears, cranial nerve avulsions, and skull fractures.

Classification by injury progression: primary versus secondary

Primary injury is due to the immediate mechanical force, whether blunt, penetrating, or blast, and may include the following:

Concussion: symptoms without intracranial injury detected on CT
Skull fracture
Contusion: localized punctate hemorrhages
Hematoma: subdural, epidural, intracerebral
Subarachnoid hemorrhage
Axonal shear or laceration.

Secondary injury refers to the evolving pathophysiological consequences of the primary injury and encompasses a multitude of complex neurobiological cascades altered or initiated at a cellular level following the primary injury, and may include the following:[16]

Cerebral edema
Increased intracranial pressure
Hemorrhage progression
Seizures
Ischemia
Infection
Traumatic venous sinus thrombosis.

Epidemiology

TBI is a substantial cause of morbidity and mortality; in the US, 60,611 TBI-related deaths occurred during 2019.[2] Annual TBI-related emergency department visits of approximately 2.5 million have been reported in the US.[17] In England and Wales, over 1 million people attend emergency departments each year with a recent head injury, and approximately 40,000 of those admitted have evidence of TBI.[18] The burden of disability and death due to TBI is higher in low- and middle-income countries compared with high-income countries.[19]

Approximately 80% to 90% of patients with TBI are treated and released without hospital admission.[20] [21]

TBI most frequently occurs in very young children (ages 0 to 4 years), and in adolescence and young adulthood (ages 15 to 24 years), with a subsequent peak in incidence in older adults (over age 65).[17] Older age comprises the group with the highest rates of TBI-related hospitalizations and deaths.[17] [2]

Estimated average annual rates of TBI are higher for males than for females across all age groups.[17] The age-adjusted rate of TBI-related deaths per 100,000 population in males (26.8 in 2018 and 26.6 in 2019) was more than three times the rate of females (8.2 in 2018 and 8.1 in 2019).[2]

Concussion and post-concussive symptoms

Concussion symptoms include short-lived confusion, disorientation, or loss of consciousness, with or without neurobehavioral deficits. Concussion symptoms occur in most patients with TBI, and are typically the only finding in patients with mild TBI. Patients with moderate or severe TBI typically have more severe neurocognitive deficits that overshadow the concussive symptoms.

The five major subtypes of concussion include headache, cognitive, vestibular, mood, and ocular-motor. One meta-analysis demonstrated that headache and cognitive symptoms are the most common subtypes in both adults and children.[22]

The World Health Organization's definition of post-concussive syndrome includes the presence of 3 or more of the following symptoms after a head injury: headache, dizziness, fatigue, irritability, difficulty with concentrating and performing mental tasks, impairment of memory, insomnia and reduced tolerance to stress, emotional excitement, or alcohol.[23]

In 2017, 15% of high school students in the US reported at least one sports-related concussion in the past year.[24] Approximately 30% of children and adults experience persistent post-concussive symptoms lasting more than 30 days after injury.[25] [26]

Hemorrhage

Subarachnoid hemorrhage (SAH) is one of the most common CT findings in TBI, occurring in about 30% to 40% of patients with moderate to severe TBI, and 5% of patients with mild TBI.[7] [27] [28] SAH is frequently associated with other intracranial injuries. SAH is associated with a poorer outcome in patients with moderate or severe TBI, although it is unclear whether the SAH is simply a marker of severity of injury, or if the poorer outcomes are due to subsequent vasospasm.[29]

Subdural hematomas (SDH) are the most common type of mass lesion in TBI, seen in about 20% of patients with moderate to severe TBI, and in about 30% of fatal TBI. SDH occur in only 3% of patients with mild TBI. SDH that lead to hospitalizations or deaths are most commonly secondary to motor vehicle-related injury in younger adults, and falls in older adults.[7] [30] [31]

Epidural hematoma (EDH) is seen in about 10% of patients with moderate to severe TBI and about 1% of patients with mild TBI. The incidence of EDH is highest among adolescents and young adults, most commonly between 20 and 30 years of age. Most cases of EDH are caused by traffic accidents, falls, and assaults.[7] [27]

Intracerebral hematomas occur in 10% to 30% of patients with moderate to severe TBI, and <1% of patients with mild TBI.[7] [16]

Cerebral contusions

Occur in 20% to 30% of patients with moderate to severe TBI, and 6% of patients with mild TBI.[7] [28] [32]

Axonal injury

Probably present in a majority of patients with TBI to some degree, although low-grade axonal injury is microscopic and not detected by CT.

Diffuse axonal injury (DAI) is thought to be present to some degree in all TBI-related fatalities and those resulting in a persistent vegetative state. The presence of DAI increases the likelihood of a poor outcome.[33] The initial CT is normal in 50% to 80% of patients ultimately diagnosed with DAI, but magnetic resonance imaging shows evidence of axonal injury in 70% of patients with moderate to severe TBI.[34]

Skull fractures

Occur in about 5% of patients with mild TBI and up to 50% of those with severe TBI. Most skull fractures are due to falls, assaults, or motor vehicle-related injuries. The most common fractures are simple linear fractures, comprising >50% of all skull fractures. Less than 1% of patients with mild TBI have a depressed skull fracture.[7]

Penetrating or blast injury

Penetrating injuries are classified as high- or low-velocity, and may be self-inflicted, non-intentional, or related to an assault. A single gunshot wound to the head has 50% mortality.[35]

Blast injuries are a leading cause of TBI in active duty military personnel in war zones, accounting for about 60% of all severe TBI.[36] [37]

Library

Adult and pediatric GCS
Hemotympanum: blood in the tympanic cavity of the middle ear (arrow)
Battle sign: superficial ecchymosis over the mastoid process
Epidural hematoma: CT brain scan showing lenticular-shaped hyperdensity between the dura mater and skull. (A-C) Same patient on different levels of the skull, (A) being the most caudal and (C) the most cranial

Citations

Key Articles

Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017 Jan 1;80(1):6-15.[Abstract][Full Text]
National Institute for Health and Care Excellence (UK). Head injury: assessment and early management. May 2023 [internet publication].[Full Text]
Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the Brain Trauma Foundation guidelines. Pediatr Crit Care Med. 2019 Mar;20(3s suppl 1):S1-82.[Abstract][Full Text]
Expert Panel on Neurological Imaging; Shih RY, Burns J, Ajam AA. ACR Appropriateness Criteria® head trauma: 2021 update. J Am Coll Radiol. 2021 May;18(5S):S13-36.[Abstract][Full Text]
Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018 Nov 1;172(11):e182853.[Abstract][Full Text]

Other Online Resources

CDC: heads up
CDC: mild TBI pocket guide
BMJ: clinical decision making tools image

Referenced Articles

1. McGinn MJ, Povlishock JT. Pathophysiology of traumatic brain injury. Neurosurg Clin N Am. 2016 Oct;27(4):397-407.[Abstract]
2. Centers for Disease Control and Prevention. Surveillance report of traumatic braininjury-related deaths by age group, sex, and mechanism of injury - United States, 2018 and 2019. 2022 [internet publication].[Full Text]
3. McCrea HJ, Perrine K, Niogi S, et al. Concussion in sports. Sports Health. 2013 Mar;5(2):160-4.[Abstract][Full Text]
4. Mower WR, Gupta M, Rodriguez R, et al. Validation of the sensitivity of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomographic (CT) decision instrument for selective imaging of blunt head injury patients: an observational study. PLoS Med. 2017 Jul;14(7):e1002313.[Abstract][Full Text]
5. Tenovuo O, Diaz-Arrastia R, Goldstein LE, et al. Assessing the severity of traumatic brain injury - time for a change? J Clin Med. 2021 Jan 4;10(1):148.[Abstract][Full Text]
6. Carney N, Totten AM, O'Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017 Jan 1;80(1):6-15.[Abstract][Full Text]
7. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT head rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6.[Abstract]
8. Smits M, Dippel DW, Steyerberg EW, et al. Predicting intracranial traumatic findings on computed tomography in patients with minor head injury: the CHIP prediction rule. Ann Intern Med. 2007 Mar 20;146(6):397-405.[Abstract]
9. Ibañez J, Arikan F, Pedraza S, et al. Reliability of clinical guidelines in the detection of patients at risk following mild head injury: results of a prospective study. J Neurosurg. 2004 May;100(5):825-34.[Abstract]
10. Türedi S, Hasanbasoglu A, Gunduz A, et al. Clinical decision instruments for CT scan in minor head trauma. J Emerg Med. 2008 Apr;34(3):253-9.[Abstract]
11. Pearson WS, Ovalle F Jr, Faul M, et al. A review of traumatic brain injury trauma center visits meeting physiologic criteria from the american college of surgeons committee on trauma/centers for disease control and prevention field triage guidelines. Prehosp Emerg Care. 2012 Jul-Sep;16(3):323-8.[Abstract]
12. Mena JH, Sanchez AI, Rubiano AM, et al. Effect of the modified Glasgow Coma Scale score criteria for mild traumatic brain injury on mortality prediction: comparing classic and modified Glasgow Coma Scale score model scores of 13. J Trauma. 2011 Nov;71(5):1185-92;discussion 1193.[Abstract][Full Text]
13. New South Wales Ministry of Health. Closed head injury in adults - initial management. Feb 2012 [internet publication].[Full Text]
14. Malec JF, Brown AW, Leibson CL, et al. The Mayo classification system for traumatic brain injury severity. J Neurotrauma. 2007 Sep;24(9):1417-24.[Abstract]
15. Ling G, Bandak F, Armonda R, et al. Explosive blast neurotrauma. J Neurotrauma. 2009 Jun;26(6):815-25.[Abstract]
16. Maas AI, Stocchetti N, Bullock R. Moderate and severe traumatic brain injury in adults. Lancet Neurol. 2008 Aug;7(8):728-41.[Abstract]
17. Taylor CA, Bell JM, Breiding MJ, et al. Traumatic brain injury-related emergency department visits, hospitalizations, and deaths - United States, 2007 and 2013. MMWR Surveill Summ. 2017 Mar 17;66(9):1-16.[Abstract][Full Text]
18. National Institute for Health and Care Excellence (UK). Head injury: assessment and early management. May 2023 [internet publication].[Full Text]
19. Maas AIR, Menon DK, Adelson PD, et al; InTBIR Participants and Investigators. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol. 2017 Dec;16(12):987-1048.[Abstract]
20. Kay A, Teasdale G. Head injury in the United Kingdom. World J Surg. 2001 Sep;25(9):1210-20.[Abstract]
21. Centers for Disease Control and Prevention. Traumatic brain injury in the United States: Emergency department visits, hospitalizations and deaths 2002-2006 (Blue Book). Mar 2010 [internet publication].[Full Text]
22. Lumba-Brown A, Teramoto M, Bloom OJ, et al. Concussion guidelines step 2: Evidence for subtype classification. Neurosurgery. 2020 Jan 1;86(1):2-13.[Abstract][Full Text]
23. World Health Organization. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992 [internet publication]. [Full Text]
24. DePadilla L, Miller GF, Jones SE, et al. Self-reported concussions from playing a sport or being physically active among high school students - United States, 2017. MMWR Morb Mortal Wkly Rep. 2018 Jun 22;67(24):682-5.[Abstract][Full Text]
25. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25.[Abstract]
26. de Koning ME, Scheenen ME, van der Horn HJ, et al. Non-hospitalized patients with mild traumatic brain injury: the forgotten minority. J Neurotrauma. 2017 Jan 1;34(1):257-61.[Abstract]
27. Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008 Aug 5;5(8):e165.[Abstract][Full Text]
28. Roberts I, Yates D, Sandercock P, et al; CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004 Oct 9-15;364(9442):1321-8.[Abstract]
29. Kramer DR, Winer JL, Pease BA, et al. Cerebral vasospasm in traumatic brain injury. Neurol Res Int. 2013;2013:415813.[Abstract][Full Text]
30. Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of acute subdural hematomas. Neurosurgery. 2006 Mar;58(3 suppl):S16-24.[Abstract]
31. Urban JE, Whitlow CT, Edgerton CA, et al. Motor vehicle crash-related subdural hematoma from real-world head impact data. J Neurotrauma. 2012 Dec 10;29(18):2774-81.[Abstract][Full Text]
32. Iaccarino C, Schiavi P, Picetti E, et al. Patients with brain contusions: predictors of outcome and relationship between radiological and clinical evolution. J Neurosurg. 2014 Apr;120(4):908-18.[Abstract]
33. van Eijck MM, Schoonman GG, van der Naalt J, et al. Diffuse axonal injury after traumatic brain injury is a prognostic factor for functional outcome: a systematic review and meta-analysis. Brain Inj. 2018;32(4):395-402.[Abstract]
34. Skandsen T, Kvistad KA, Solheim O, et al. Prevalence and impact of diffuse axonal injury in patients with moderate and severe head injury: a cohort study of early magnetic resonance imaging findings and 1-year outcome. J Neurosurg. 2010 Sep;113(3):556-63.[Abstract]
35. Cripps MW, Ereso AQ, Sadjadi J, et al. The number of gunshot wounds does not predict injury severity and mortality. Am Surg. 2009 Jan;75(1):44-8.[Abstract]
36. DuBose JJ, Barmparas G, Inaba K, et al. Isolated severe traumatic brain injuries sustained during combat operations: demographics, mortality outcomes, and lessons to be learned from contrasts to civilian counterparts. J Trauma. 2011 Jan;70(1):11-8.[Abstract]
37. Ling G, Ecklund JM, Bandak FA. Brain injury from explosive blast: description and clinical management. Handb Clin Neurol. 2015;127:173-80.[Abstract]
38. MRC CRASH Trial Collaborators; Perel P, Arango M, Clayton T, et al. Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ. 2008 Feb 23;336(7641):425-9.[Abstract][Full Text]
39. Beedham W, Peck G, Richardson SE, et al. Head injury in the elderly - an overview for the physician. Clin Med (Lond). 2019 Mar;19(2):177-84.[Abstract][Full Text]
40. Halstead ME, Walter KD, Moffatt K, et al. Sport-related concussion in children and adolescents. Pediatrics. 2018 Dec;142(6):e20183074.[Abstract][Full Text]
41. Servadei F, Murray GD, Teasdale GM, et al. Traumatic subarachnoid hemorrhage: demographic and clinical study of 750 patients from the European brain injury consortium survey of head injuries. Neurosurgery. 2002 Feb;50(2):261-9.[Abstract]
42. Cepeda S, Gómez PA, Castaño-Leon AM, et al. Traumatic intracerebral hemorrhage: risk factors associated with progression. J Neurotrauma. 2015 Aug 15;32(16):1246-53.[Abstract]
43. 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. 2021 Feb;34(1):312-24.[Abstract][Full Text]
44. Taber KH, Warden DL, Hurley RA. Blast-related traumatic brain injury: what is known? J Neuropsychiatry Clin Neurosci. 2006 Spring;18(2):141-5.[Abstract]
45. Committee on Trauma, American College of Surgeons. ATLS: Advanced trauma life support program for doctors. 10th ed. Chicago, IL: American College of Surgeons; 2018.
46. Kochanek PM, Tasker RC, Carney N, et al. Guidelines for the management of pediatric severe traumatic brain injury, third edition: update of the Brain Trauma Foundation guidelines. Pediatr Crit Care Med. 2019 Mar;20(3s suppl 1):S1-82.[Abstract][Full Text]
47. Sarrafzadeh AS, Peltonen EE, Kaisers U, et al. Secondary insults in severe head injury - do multiply injured patients do worse? Crit Care Med. 2001 Jun;29(6):1116-23.[Abstract]
48. Holly LT, Kelly DF, Counelis GJ, et al. Cervical spine trauma associated with moderate and severe head injury: incidence, risk factors, and injury characteristics. J Neurosurg. 2002 Apr;96(3 suppl):285-91.[Abstract]
49. Warner KJ, Cuschieri J, Copass MK, et al. The impact of prehospital ventilation on outcome after severe traumatic brain injury. J Trauma. 2007 Jun;62(6):1330-8.[Abstract]
50. Badjatia N, Carney N, Crocco TJ, et al; Brain Trauma Foundation; BTF Center for Guidelines Management. Guidelines for prehospital management of traumatic brain injury 2nd edition. Prehosp Emerg Care. 2008;12(suppl 1):S1-52.[Abstract]
51. American College of Surgeons: ACS TQIP best practices in the management of traumatic brain injury. Jan 2015 [internet publication].[Full Text]
52. Davis DP. Early ventilation in traumatic brain injury. Resuscitation. 2008 Mar;76(3):333-40.[Abstract]
53. Davis DP, Dunford JV, Ochs M, et al. The use of quantitative end-tidal capnometry to avoid inadvertent severe hyperventilation in patients with head injury after paramedic rapid sequence intubation. J Trauma. 2004 Apr;56(4):808-14.[Abstract]
54. Marmarou A, Saad A, Aygok G, et al. Contribution of raised ICP and hypotension to CPP reduction in severe brain injury: correlation to outcome. Acta Neurochir Suppl. 2005;95:277-80.[Abstract]
55. Manley G, Knudson MM, Morabito D, et al. Hypotension, hypoxia, and head injury: frequency, duration, and consequences. Arch Surg. 2001 Oct;136(10):1118-23.[Abstract][Full Text]
56. Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma. 1993 Feb;34(2):216-22.[Abstract]
57. Kokoska ER, Smith GS, Pittman T, et al. Early hypotension worsens neurological outcome in pediatric patients with moderately severe head trauma. J Pediatr Surg. 1998 Feb;33(2):333-8.[Abstract]
58. Berry C, Ley EJ, Bukur M, et al. Redefining hypotension in traumatic brain injury. Injury. 2012 Nov;43(11):1833-7.[Abstract]
59. Johnson MA, Borgman MA, Cannon JW, et al. Severely elevated blood pressure and early mortality in children with traumatic brain injuries: the neglected end of the spectrum. West J Emerg Med. 2018 May;19(3):452-9.[Abstract][Full Text]
60. Wiegers EJA, Lingsma HF, Huijben JA, et al. Fluid balance and outcome in critically ill patients with traumatic brain injury (CENTER-TBI and OzENTER-TBI): a prospective, multicentre, comparative effectiveness study. Lancet Neurol. 2021 Aug;20(8):627-38.[Abstract][Full Text]
61. Rossi S, Picetti E, Zoerle T, et al. Fluid management in acute brain injury. Curr Neurol Neurosci Rep. 2018 Sep 11;18(11):74.[Abstract]
62. Myburgh J, Cooper DJ, Finfer S, et al. SAFE Study Investigators; Australian and New Zealand Intensive Care Society Clinical Trials Group; Australian Red Cross Blood Service; George Institute for International Health. Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med. 2007 Aug 30;357(9):874-84.[Abstract][Full Text]
63. Spahn DR, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98.[Abstract][Full Text]
64. Polites SF, Moody S, Williams RF, et al. Timing and volume of crystalloid and blood products in pediatric trauma: an Eastern Association for the Surgery of Trauma multicenter prospective observational study. J Trauma Acute Care Surg. 2020 Jul;89(1):36-42.[Abstract]
65. Mbadiwe N, Georgette N, Slidell MB, et al. Higher crystalloid volume during initial pediatric trauma resuscitation is associated with mortality. J Surg Res. 2021 Jun;262:93-100.[Abstract]
66. Yu PP. Care of kidney transplant patients using different immunosuppressive drugs [in Chinese]. Zhonghua Hu Li Za Zhi. 1987 Apr;22(4):165-6.[Abstract]
67. Gill MR, Reiley DG, Green SM. Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med. 2004 Feb;43(2):215-23.[Abstract]
68. Tesseris J, Pantazidis N, Routsi C, et al. A comparative study of the Reaction Level Scale (RLS 85) with Glasgow Coma Scale (GCS) and Edinburgh-2 Coma Scale (Modified) (E2CS(M)). Acta Neurochir (Wien). 1991;110(1-2):65-76.[Abstract]
69. Elliott M. Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs. 1996 Aug;28(4):213-4.[Abstract]
70. Lindsay KW, Teasdale GM, Knill-Jones RP. Observer variability in assessing the clinical features of subarachnoid hemorrhage. J Neurosurg. 1983 Jan;58(1):57-62.[Abstract]
71. Menegazzi J, Davis EA, Sucov AN, et al. Reliability of the Glasgow Coma Scale when used by emergency physicians and paramedics. J Trauma. 1993 Jan;34(1):46-8.[Abstract]
72. Singh B, Murad MH, Prokop LJ, et al. Meta-analysis of Glasgow coma scale and simplified motor score in predicting traumatic brain injury outcomes. Brain Inj. 2013;27(3):293-300.[Abstract][Full Text]
73. Kupas DF, Melnychuk EM, Young AJ. Glasgow Coma Scale motor component ("patient does not follow commands") performs similarly to total Glasgow Coma Scale in predicting severe injury in trauma patients. Ann Emerg Med. 2016 Dec;68(6):744-50.[Abstract][Full Text]
74. Nyam TE, Ao KH, Hung SY, et al. FOUR score predicts early outcome in patients after traumatic brain injury. Neurocrit Care. 2017 Apr;26(2):225-31.[Abstract]
75. Kasprowicz M, Burzynska M, Melcer T, et al. A comparison of the Full Outline of UnResponsiveness (FOUR) score and Glasgow Coma Score(GCS) in predictive modelling in traumatic brain injury. Br J Neurosurg. 2016;30(2):211-20.[Abstract]
76. Meyer S, Gibb T, Jurkovich GJ. Evaluation and significance of the pupillary light reflex in trauma patients. Ann Emerg Med. 1993 Jun;22(6):1052-7.[Abstract]
77. CRASH-2 collaborators; Roberts I, Shakur H, Afolabi A, et al. The importance of early treatment with tranexamic acid in bleeding trauma patients: an exploratory analysis of the CRASH-2 randomised controlled trial. Lancet. 2011 Mar 26;377(9771):1096-101;1101;e1-2.[Abstract]
78. CRASH-2 trial collaborators; Shakur H, Roberts I, Bautista R, et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet. 2010 Jul 3;376(9734):23-32.[Abstract][Full Text]
79. Karl V, Thorn S, Mathes T, et al. Association of tranexamic acid administration with mortality and thromboembolic events in patients with traumatic injury: a systematic review and meta-analysis. JAMA Netw Open. 2022 Mar 1;5(3):e220625.[Abstract][Full Text]
80. El-Menyar A, Sathian B, Asim M, et al. Efficacy of prehospital administration of tranexamic acid in trauma patients: a meta-analysis of the randomized controlled trials. Am J Emerg Med. 2018 Jun;36(6):1079-87.[Abstract]
81. Lawati KA, Sharif S, Maqbali SA, et al. Efficacy and safety of tranexamic acid in acute traumatic brain injury: a systematic review and meta-analysis of randomized-controlled trials. Intensive Care Med. 2021 Jan;47(1):14-27.[Abstract]
82. Yokobori S, Yatabe T, Kondo Y, et al. Efficacy and safety of tranexamic acid administration in traumatic brain injury patients: a systematic review and meta-analysis. J Intensive Care. 2020 Jul 3;8:46. [Abstract][Full Text]
83. July J, Pranata R. Tranexamic acid is associated with reduced mortality, hemorrhagic expansion, and vascular occlusive events in traumatic brain injury - meta-analysis of randomized controlled trials. BMC Neurol. 2020 Apr 6;20(1):119.[Abstract][Full Text]
84. Zehtabchi S, Abdel Baki SG, Falzon L, et al. Tranexamic acid for traumatic brain injury: a systematic review and meta-analysis. Am J Emerg Med. 2014 Dec;32(12):1503-9.[Abstract][Full Text]
85. Haddad SH, Arabi YM. Critical care management of severe traumatic brain injury in adults. Scand J Trauma Resusc Emerg Med. 2012 Feb 3;20:12.[Abstract][Full Text]
86. Alarcon JD, Rubiano AM, Okonkwo DO, et al. Elevation of the head during intensive care management in people with severe traumatic brain injury. Cochrane Database of Syst Rev. 2017 Dec 28;12(12):CD009986.[Abstract][Full Text]
87. Chen H, Song Z, Dennis JA. Hypertonic saline versus other intracranial pressure-lowering agents for people with acute traumatic brain injury. Cochrane Database Syst Rev. 2020 Jan 17;(1):CD010904.[Abstract][Full Text]
88. Susanto M, Riantri I. Optimal dose and concentration of hypertonic saline in traumatic brain injury: a systematic review. Medeni Med J. 2022 Jun 23;37(2):203-11.[Abstract][Full Text]
89. Mellion SA, Bennett KS, Ellsworth GL, et al. High-dose barbiturates for refractory intracranial hypertension in children with severe traumatic brain injury. Pediatr Crit Care Med. 2013 Mar;14(3):239-47.[Abstract]
90. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(suppl 1):S1-106.[Abstract]
91. Shen L, Wang Z, Su Z, et al. Effects of intracranial pressure monitoring on mortality in patients with severe traumatic brain injury: a meta-analysis. PLoS One. 2016 Dec 28;11(12):e0168901.[Abstract][Full Text]
92. Sahuquillo J, Dennis JA. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev. 2019 Dec 31;12(12):CD003983.[Abstract][Full Text]
93. Hawryluk GWJ, Rubiano AM, Totten AM, et al. Guidelines for the management of severe traumatic brain injury: 2020 update of the decompressive craniectomy recommendations. Neurosurgery. 2020 Sep 1;87(3):427-34.[Abstract][Full Text]
94. Clifton GL, Valadka A, Zygun D, et al. Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol. 2011 Feb;10(2):131-9.[Abstract]
95. Cooper DJ, Nichol AD, Bailey M, et al; POLAR Trial Investigators and the ANZICS Clinical Trials Group. Effect of early sustained prophylactic hypothermia on neurologic outcomes among patients with severe traumatic brain injury: the POLAR randomized clinical trial. JAMA. 2018 Dec 4;320(21):2211-20.[Abstract][Full Text]
96. Dowlatshahi D, Butcher KS, Asdaghi N, et al. Poor prognosis in warfarin-associated intracranial hemorrhage despite anticoagulation reversal. Stroke. 2012 Jul;43(7):1812-7.[Abstract][Full Text]
97. Sun Y, Wang J, Wu X, et al. Validating the incidence of coagulopathy and disseminated intravascular coagulation in patients with traumatic brain injury - analysis of 242 cases. Br J Neurosurg. 2011 Jun;25(3):363-8.[Abstract]
98. Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: guidance from the Anticoagulation Forum. Am J Hematol. 2019 Jun;94(6):697-709.[Abstract][Full Text]
99. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Mild Traumatic Brain Injury; Valente JH, Anderson JD, Paolo WF, et al. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with mild traumatic brain injury: approved by ACEP board of directors, February 1, 2023 clinical policy endorsed by the Emergency Nurses Association (April 5, 2023). Ann Emerg Med. 2023 May;81(5):e63-105.[Abstract][Full Text]
100. Vos PE, Alekseenko Y, Battistin L, et al. Mild traumatic brain injury. Eur J Neurol. 2012 Feb;19(2):191-8.[Abstract][Full Text]
101. Fuller GW, Evans R, Preston L, et al. Should adults with mild head injury who are receiving direct oral anticoagulants undergo computed tomography scanning? A systematic review. Ann Emerg Med. 2019 Jan;73(1):66-75.[Abstract][Full Text]
102. Murray GD, Butcher I, McHugh GS, et al. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma. 2007 Feb;24(2):329-37.[Abstract]
103. Laroche M, Kutcher ME, Huang MC, et al. Coagulopathy after traumatic brain injury. Neurosurgery. 2012 Jun;70(6):1334-45.[Abstract]
104. Brown CV, Sowery L, Curry E, et al. Recombinant factor VIIa to correct coagulopathy in patients with traumatic brain injury presenting to outlying facilities before transfer to the regional trauma center. Am Surg. 2012 Jan;78(1):57-60.[Abstract]
105. Lombardo S, Millar D, Jurkovich GJ, et al. Factor VIIa administration in traumatic brain injury: an AAST-MITC propensity score analysis. Trauma Surg Acute Care Open. 2018 Mar 22;3(1):e000134. [Abstract][Full Text]
106. Easter JS, Haukoos JS, Claud J, et al. Traumatic intracranial injury in intoxicated patients with minor head trauma. Acad Emerg Med. 2013 Aug;20(8):753-60.[Abstract][Full Text]
107. Maguire SA, Watts PO, Shaw AD, et al. Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review. Eye (Lond). 2013 Jan;27(1):28-36.[Abstract][Full Text]
108. Hoffmann M, Lefering R, Rueger JM, et al. Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality. Br J Surg. 2012 Jan;99(suppl 1):122-30.[Abstract]
109. Compagnone C, d'Avella D, Servadei F, et al. Patients with moderate head injury: a prospective multicenter study of 315 patients. Neurosurgery. 2009 Apr;64(4):690-6;discussion 696-7.[Abstract]
110. Stuke L, Diaz-Arrastia R, Gentilello LM, et al. Effect of alcohol on Glasgow Coma Scale in head-injured patients. Ann Surg. 2007 Apr;245(4):651-5.[Abstract][Full Text]
111. Lange RT, Iverson GL, Brubacher JR, et al. Effect of blood alcohol level on Glasgow Coma Scale scores following traumatic brain injury. Brain Inj. 2010;24(7-8):919-27.[Abstract]
112. Simundic AM, Bölenius K, Cadamuro J, et al. Joint EFLM-COLABIOCLI recommendation for venous blood sampling. Clin Chem Lab Med. 2018;56(12):2015-38.[Abstract]
113. Hatchimonji JS, Dumas RP, Kaufman EJ, et al. Questioning dogma: does a GCS of 8 require intubation? Eur J Trauma Emerg Surg. 2021 Dec;47(6):2073-9.[Abstract][Full Text]
114. Expert Panel on Neurological Imaging; Shih RY, Burns J, Ajam AA. ACR Appropriateness Criteria® head trauma: 2021 update. J Am Coll Radiol. 2021 May;18(5S):S13-36.[Abstract][Full Text]
115. Bullock MR, Chesnut R, Ghajar J, et al; Surgical Management of Traumatic Brain Injury Author Group. Surgical management of traumatic parenchymal lesions. Neurosurgery. 2006 Mar;58(3 suppl):S25-46;discussion Si-iv.[Abstract]
116. Expert Panel on Pediatric Imaging; Ryan ME, Pruthi S, Desai NK, et al. ACR Appropriateness Criteria® head trauma - child. J Am Coll Radiol. 2020 May;17(5s):S125-37.[Abstract][Full Text]
117. Lindberg DM, Stence NV, Grubenhoff JA, et al. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics. 2019 Oct;144(4):e20190419.[Abstract][Full Text]
118. Geeraerts T, Velly L, Abdennour L, et al. Management of severe traumatic brain injury (first 24 hours). Anaesth Crit Care Pain Med. 2018 Apr;37(2):171-86.[Abstract][Full Text]
119. Roldán M, Abay TY, Kyriacou PA. Non-invasive techniques for multimodal monitoring in traumatic brain injury: systematic review and meta-analysis. J Neurotrauma. 2020 Dec 1;37(23):2445-53.[Abstract]
120. Caldas J, Bittencourt Rynkowski C, Robba C. POCUS, how can we include the brain? An overview. J Anesth Analg Crit Care. 2022;2:55.[Full Text]
121. Ruff RM, Iverson GL, Barth JT, et al; NAN Policy and Planning Committee. Recommendations for diagnosing a mild traumatic brain injury: a National Academy of Neuropsychology education paper. Arch Clin Neuropsychol. 2009 Feb;24(1):3-10.[Abstract]
122. Aoki Y, Inokuchi R, Gunshin M, et al. Diffusion tensor imaging studies of mild traumatic brain injury: a meta-analysis. J Neurol Neurosurg Psychiatry. 2012 Sep;83(9):870-6.[Abstract][Full Text]
123. Kraus MF, Susmaras T, Caughlin BP, et al. White matter integrity and cognition in chronic traumatic brain injury: a diffusion tensor imaging study. Brain. 2007 Oct;130(Pt 10):2508-19.[Abstract][Full Text]
124. Pandor A, Goodacre S, Harnan S, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011 Aug;15(27):1-202.[Abstract][Full Text]
125. Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1511-8.[Abstract][Full Text]
126. Stein SC, Fabbri A, Servadei F, et al. A critical comparison of clinical decision instruments for computed tomographic scanning in mild closed traumatic brain injury in adolescents and adults. Ann Emerg Med. 2009 Feb;53(2):180-8.[Abstract]
127. Smits M, Dippel DW, de Haan GG, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519-25.[Abstract][Full Text]
128. Papa L, Stiell IG, Clement CM, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012 Jan;19(1):2-10.[Abstract][Full Text]
129. Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100-5.[Abstract][Full Text]
130. Lumba-Brown A, Yeates KO, Sarmiento K, et al. Centers for Disease Control and Prevention guideline on the diagnosis and management of mild traumatic brain injury among children. JAMA Pediatr. 2018 Nov 1;172(11):e182853.[Abstract][Full Text]
131. Dunning J, Daly JP, Lomas JP, et al. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 Nov;91(11):885-91.[Abstract][Full Text]
132. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010 Mar 9;182(4):341-8.[Abstract][Full Text]
133. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70.[Abstract]
134. Babl FE, Borland ML, Phillips N, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017 Jun 17;389(10087):2393-402.[Abstract]
135. Almenawer SA, Bogza I, Yarascavitch B, et al. The value of scheduled repeat cranial computed tomography after mild head injury: single-center series and meta-analysis. Neurosurgery. 2013 Jan;72(1):56-62;discussion 63-4.[Abstract]
136. Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council; Graham R, Rivara FP, Ford MA, et al. Sports-related concussions in youth: improving the science, changing the culture. Washington (DC): National Academies Press (US); 2014.[Abstract][Full Text]
137. Blostein P, Jones SJ. Identification and evaluation of patients with mild traumatic brain injury: results of a national survey of level I trauma centers. J Trauma. 2003 Sep;55(3):450-3.[Abstract]
138. Servadei F, Teasdale G, Merry G. Defining acute mild head injury in adults: a proposal based on prognostic factors, diagnosis, and management. J Neurotrauma. 2001 Jul;18(7):657-64.[Abstract]
139. Ropper AH, Gorson KC. Clinical practice: concussion. N Engl J Med. 2007 Jan 11;356(2):166-72.[Abstract]
140. Provenzale J. CT and MR imaging of acute cranial trauma. Emerg Radiol. 2007 Apr;14(1):1-12.[Abstract]
141. Graham DI, Gennarelli TA. Trauma. In: Graham DI, Lantos PL, eds. Greenfield's neuropathology. 6th ed. London: Edward Arnold; 1997:197-248.
142. Sommargren CE. Electrocardiographic abnormalities in patients with subarachnoid hemorrhage. Am J Crit Care. 2002 Jan;11(1):48-56.[Abstract]