Cerebral Contusion

What is Cerebral Contusion?

Traumatic brain injury (TBI), or brain damage caused by a severe blow to the head, is considered the most serious type of trauma. It often results in lasting emotional, behavioral, and physical issues.¹² About half of those who survive and are hospitalized due to a TBI are left with long-term disabilities. TBIs can involve various types of brain damage, but one of the most dangerous is called a hemorrhagic cerebral contusion. A TBI coupled with a cerebral contusion significantly increases the risk of disability and death.

In a cerebral contusion, the brain’s tissues suffer permanent damage. The extent of the damage depends on how severe the initial injury was and what happened after the impact. This could include increased damage caused by reactions in the body that happen after the primary injury. The impact to the head causes a hemorrhagic lesion, or a region of damaged tissue where bleeding occurs, immediately after the injury.³

Cerebral contusions can get worse and become larger. In many cases, there may be multiple hemorrhagic contusions. These contusions occur in the brain tissue and often result in a loss of function in the affected area. It’s important to remember that blood can be harmful to healthy brain tissue, which is why these contusions can be particularly damaging. The bleeding in the brain associated with contusions results from damage to tiny blood vessels during the initial injury. This leads scientists to believe that the formation of a contusion might be related to blood clotting problems, either presenting before the injury or developing as a result of it.

What Causes Cerebral Contusion?

Cerebral contusion, or a bruise on the brain, often occurs due to a head injury. These injuries usually involve a blow to the head, but can sometimes also happen if the head is penetrated.

There are many circumstances which might lead to such a traumatic event:

* Car accidents
* Tripping or falling
* Violent acts
* Injuries during recreational activities
* Sports-related injuries
* Cycling accidents
* Domestic abuse
* Child abuse
* Injuries from an explosion or blast

Risk Factors and Frequency for Cerebral Contusion

Traumatic brain injuries (TBI) are a major global health concern, leading to disability, death and a significant economic cost. In the United States alone, 2.8 million TBIs occur every year, with a third of these happening in children. Each year, more than 250,000 patients are hospitalized for nonfatal TBI, with 10% of hospitalizations relating to children. Unfortunately, over 50,000 patients lose their lives to TBIs each year, with children constituting 4.5% of these deaths.

Typically, sports-related TBI often present as superficial injuries and cerebral contusions. A year on from hospitalization for TBI, about 43% Americans live with some form of lasting disability, whether physical, cognitive, behavioral, or emotional. In terms of self-reported head injury, it’s prevalent among 15.7% of adults over 40 years old in the US, with a higher incidence among men and non-Hispanic whites.

In the European Union, TBI results in a million hospitalizations each year and causes the most deaths after road accidents, especially among young people. When looking into Chinese data on head trauma, it’s clear that the severity of cerebral contusions significantly influences survival rates. Having multiple cerebral contusions or intracranial hematomas significantly increases the mortality rate in TBI patients.

In terms of recreational incidents that lead to TBI, cerebral contusion is the most common consequence followed by traumatic subarachnoid hemorrhage, subdural hematoma and epidural hematoma. Interestingly, cerebral contusions are more common in adults over 60 and children suffering from TBI often exhibit brain edema, skull fracture and brain contusion.

Lastly, males have twice the risk of getting a TBI compared to females. But, once a TBI does occur, the chances of survival are relatively equal between males and females.

Signs and Symptoms of Cerebral Contusion

When someone experiences a traumatic event, healthcare providers conduct an initial trauma assessment. They start by making sure the patient is properly stabilized. Next, they use rapid imaging studies to identify any potentially severe injuries that may require surgery. It’s important to keep the patient’s spine immobilized until they’ve confirmed that it’s stable. Once stability is established, they gather information about how the injury happened from the patient, their family members, or paramedics.

A thorough neurological examination is also performed. To do this, the healthcare team may need to temporarily stop any pain-relieving sedatives to make sure they’re getting an accurate picture of the patient’s response to stimuli. They check the patient’s reactions in three areas: eye movement, motor skills, and verbal responses. They use a set of guidelines called the Glasgow coma scale to score the patient’s responses in each of these areas. Established in 1974 by Teasdale and Jennett, the Glasgow coma scale helps communicate a patient’s status to the healthcare team and makes it easier to compare future evaluations. The patient’s pupil response is a crucial part of this initial assessment.

The Glasgow coma scale includes:

• Eye opening (score ranges from 1 to 4):
  • Spontaneous – 4
  • To speech – 3
  • To pain – 2
  • No response – 1
• Verbal function (score ranges from 1 to 5):
  • Alert and oriented – 5
  • Confused/disoriented – 4
  • Inappropriate words – 3
  • Incomprehensible sounds – 2
  • No response – 1
• Motor function (score ranges from 1 to 6):
  • Obeys commands – 6
  • Localizes pain – 5
  • Withdraws from pain – 4
  • Decorticate flexion – 3
  • Decerebrate extension – 2
  • No response – 1

Testing for Cerebral Contusion

In case of a trauma situation, certain procedures and test should typically be carried out. These include taking X-rays of the entire spine, chest, pelvis, and any other bones that might be involved or damaged.

Apart from this, various blood tests should also be done. These tests are done to evaluate your overall health and ensure that there is no harmful substance present in your body.

If your breathing is affected or you are not breathing naturally and need help, a test known as ‘arterial blood gases’ needs to be performed.

In case of concussion symptoms like loss of consciousness, persistent vomiting, seizures, or if there are certain unusual signs during a routine neurological examination, a head CT scan might be performed. The scan might show areas of varying densities in the brain, often surrounded by low-density areas. As time passes, more swelling can be seen. Sometimes many focal injuries may give a “salt and pepper” appearance. The scan also helps in checking for fractures in the skull.

It’s important to note that even though an MRI is a very accurate tool for examining brain injuries, it is not usually done during the initial stages of treating a head injury. If performed, it might show areas of varying intensities, and can also reveal minor brain hemorrhages or brain damage. An MRI can be used later if there are cognitive problems or issues related to mental processes like learning, thinking, perception, etc.

Treatment Options for Cerebral Contusion

After a severe head injury, the first steps are to ensure that the person can breathe properly, their heart is working adequately, and they’re well supplied with oxygen and fluids delivered via an intravenous drip. If needed, a tube may be inserted into their airway to help them breathe. It’s crucial to avoid a lack of oxygen and low blood pressure, as these could worsen the person’s condition.”

If a CT scan of the person’s head shows no immediate need for neurosurgery, the focus then shifts to managing the pressure inside their skull. This is important because excessive pressure can cause further damage to their brain. If the person’s Glasgow Coma Scale (GCS) score, a measure of consciousness, is below 8, pressure monitoring becomes vital. A ventricular drain may be used to remove a fluid called cerebrospinal fluid (CSF) which can help reduce the pressure. If the person suffers from cerebral contusions, or bruises on the brain, they may be given preventive medication for about a week to stop possible seizures after the injury.

The aim of treatment is keeping the pressure inside the skull below a certain level and the cerebral perfusion pressure (CPP), which measures blood flow to the brain, above a particular level. Drug sedation, diuretics (medicines that make the person urinate more often) and a salt solution called hypertonic saline may be used to manage high internal skull pressure.

In some cases, immediate surgery may be needed to evacuate or remove the bruised area of the brain. Indications for surgical removal may include ongoing decline in neurological condition, signs of pressure on brain imaging, shifting of the brain’s midline more than a certain amount, evidence of fluid-filled spaces in the brain being compressed, or large bruise volumes. In extreme cases unresponsive to standard pressure reduction measures, a surgery called decompressive craniectomy may be performed, which involves removing part of the skull to relieve the internal pressure.

However, this procedure results in a significant number of patients ending up in a vegetative state and there’s a risk of up to 87% of bleeding or bruise growth. Corticosteroids, a type of hormone, are not recommended for managing increased skull pressure. Within 72 hours, it’s important to start nutritional support for the person through a feeding tube.

In 2015, the American College of Surgeons recommended a three-tiered strategy for managing increased intracranial pressure. The first step includes measures like raising the head of the bed, using sedation for relief, draining fluid intermittently, and repeating head imaging if the pressure doesn’t improve. The second step expands upon these measures by altering the pressure-monitoring device, using a therapy to eliminate excessive water, aiming for a specific blood flow value, maintaining a certain carbon dioxide level in the blood, and considering the use of muscle-relaxing drugs.

As a last resort, the third step may involve surgery to remove part of the skull, using continuous paralysis-inducing drugs, putting the person into a coma-like state with specific drugs, or as a salvage therapy, reducing the body temperature if all previous steps have failed.

What else can Cerebral Contusion be?

After a traumatic event, it is generally easy to identify a brain bruise. However, in rare cases, a patient may initially experience non-traumatic bleeding which then leads to a traumatic event. These can include:

• A brain tumor with sudden bleeding
• Bleeding within the brain tissue due to a burst aneurysm
• Bleeding due to high blood pressure
• Stroke followed by reperfusion bleeding

What to expect with Cerebral Contusion

The likelihood of a patient’s survival after head injury decreases as their Glasgow Coma Scale (a method for assessing a patient’s level of consciousness) score goes down. The age of the patient and the nature of the injury are the most determining factors for patient’s recovery.

A longer period of unconsciousness is usually a sign of more severe disability. In the case of moderate head injuries, about 60% of patients are able to recover well, but 25% may experience some level of lasting disability. For patients with severe head injuries, only 25% to 33% have positive outcomes. These patients may continue to experience issues like lack of concentration, memory loss, and even personality changes. Brain bruising is a key factor that might lead to seizures after trauma.

Recently, the responsiveness of a patient’s pupils is used to estimate outcome after head injury. In this method, the Glasgow Coma Scale score is subtracted from the number of unresponsive pupils a patient has. For example, if a patient with a Glasgow Coma Scale score of 3 and unresponsive pupils, the chances of survival six months after injury are put at 74%, while 90% are expected to have an unfavorable outcome. These percentages change depending on the pupil responsiveness.

Older age greatly increases the risk of death and poor recovery six months after a traumatic brain injury. In a study, the presence of individual CT findings (like brain bleeding or blood in the fluid-filled areas around the brain) didn’t vary much between patients. However, if these findings were combined, there was a pattern showing increased chances of poor outcomes.

The Glasgow Outcome Scale (a tool to measure recovery after brain injury) uses a 5-point scale:
– Score 5: The patient can get back to their normal life with minor disabilities.
– Score 4: The patient lives independently but with more significant disabilities.
– Score 3: The patient is conscious, but depends on others for day-to-day care.
– Score 2: The patient is not conscious. Their eyes may be open, and they might respond to movement.
– Score 1: The patient has died.

Certain classifications have been developed to predict the outcomes after a traumatic brain injury. These take into account things like whether the middle line of the brain has shifted, whether the fluid-filled spaces around the brain are open, the size of any brain bleed, and whether surgery has been carried out. One of these, the Rotterdam CT score has recently been confirmed as a reliable predictive tool in recent studies.

Possible Complications When Diagnosed with Cerebral Contusion

Here are some of the possible effects or consequences following a head injury:

• Seizures
• Excessive accumulation of fluid in the brain, called Hydrocephalus
• Loss of sense of smell, known as Posttraumatic anosmia
• Severe disability
• Coma
• Death
• Missing school or work
• Unable to work for a certain period or permanently
• Difficulty in concentrating, paying attention, and remembering things
• Problems with mental abilities
• Changes in personality
• Posttraumatic stress disorder (an anxiety disorder after a distressing event)
• Infections after surgery

Preventing Cerebral Contusion

A brain contusion, or a bruise on the brain, can be a serious condition. It can result in severe health problems, leading to things like comas or even death. This condition not only greatly impacts the patient but also puts a lot of strain on their family. It can be expensive to treat too, as it often leads to long hospital stays and intense rehabilitation. Most of the costs are linked to these prolonged hospital stays and the rehabilitation required for patient recovery.

Therefore, it’s essential to take steps to prevent brain contusions. Here are some simple yet effective steps patients or parents can take to reduce the risk:

• Encourage cyclists to wear helmets.
• Always wear seatbelts when in a car.
• Ensure children are properly restrained in vehicles.
• Keep a close watch on younger children to prevent accidents.
• When cycling or skateboarding, try to stick to even surfaces rather than uneven or unpaved ones.
• In certain sports, make sure to wear appropriate protective headgear like helmets.

By following these guidelines, you can help reduce the risk of this serious injury occurring.