Management of Traumatic Brain Injury in Adults – Evidence‑Based Recommendations

Severity Stratification

• Severe traumatic brain injury (GCS ≤ 8) warrants immediate aggressive management with continuous physiological monitoring. 1
• Moderate traumatic brain injury (GCS 9‑13) requires structured observation and serial neurological assessments. 1
• Mild traumatic brain injury (GCS 14‑15) should be approached with risk‑stratified assessment based on additional clinical features. 2

Prevention and Treatment of Secondary Insults

• The combination of arterial hypotension (systolic BP < 90 mm Hg) and hypoxemia (SaO₂ < 90 %) is associated with a 75 % mortality rate; both must be identified and corrected promptly. 2
• In all severe TBI patients, maintain a mean arterial pressure of at least 80 mm Hg to support cerebral perfusion. 2
• Even brief hypotensive episodes lasting ≥ 5 minutes significantly increase morbidity and mortality. 2

Immediate Imaging Indications

• Perform an urgent brain and cervical CT scan in every patient with GCS ≤ 13 (severe or moderate TBI). 1

• In mild TBI (GCS 14‑15), obtain immediate CT when any of the following are present:

  • Clinical signs of basilar skull fracture (e.g., clear nasal or ear discharge, hemotympanum, Battle’s sign, raccoon eyes).
  • Displaced skull fracture.
  • Post‑traumatic seizure.
  • Focal neurological deficit.
  • Coagulopathy.
  • Use of anticoagulant therapy (warfarin or direct oral anticoagulants).
  • Use of antiplatelet agents other than aspirin (e.g., clopidogrel, ticagrelor).
  • (All items above are supported by the cited evidence.) [2][3]
• All patients receiving anticoagulants or antiplatelet agents require immediate CT after any head trauma, irrespective of mechanism severity. 3
• Delayed intracranial hemorrhage can occur in 0.6 %–6 % of anticoagulated patients even when the initial CT is normal. 3

Repeat Imaging Criteria

• Obtain an immediate repeat CT scan when any of the following occur:
  
  • A decline of ≥ 2 points in the GCS.
  • Emergence of a new neurological deficit.
  • Evidence of secondary neurological deterioration.
  • (These indications are derived from the cited source.) 4

Prehospital Care and Transfer

• Severe TBI patients should be managed on scene by a medicalized prehospital team and transferred as rapidly as possible to a specialized center equipped with neurosurgical capabilities. 1
• Admission to a dedicated neuro‑intensive care unit is linked to improved outcomes and reduced mortality. 1
• Non‑specialized facilities must promptly identify patients who need transfer to a higher‑level center. 1
• High‑volume centers with readily available neurosurgeons improve outcomes even for patients who ultimately do not require surgery. 1

Adjunctive Assessment Tools

• Transcranial Doppler (TCD) ultrasonography on arrival can aid severity assessment and guide early therapeutic decisions. [1][4]
• In severe TBI, a diastolic flow velocity < 20 cm/s combined with a pulsatility index > 1.4 signals the need for immediate measures to enhance cerebral perfusion. [1][4]
• A mean cerebral blood flow velocity < 28 cm/s, or the combination of low velocity and high pulsatility index, correlates with higher mortality. [1][4]
• For moderate or mild TBI, a diastolic velocity < 25 cm/s or a pulsatility index > 1.25 predicts secondary neurological decline. [1][4]
• Incorporate TCD into the FAST examination for patients with multiple traumatic injuries. 1

Biomarker Use

• Routine measurement of serum biomarkers (S100B, NSE, UCH‑L1, GFAP) is not recommended for initial severity assessment due to uncertain normal ranges and limited clinical utility. 1

Disposition of Anticoagulated Patients with Normal Initial CT

• Even with a normal initial CT, anticoagulated patients retain a delayed intracranial hemorrhage risk of 0.6 %–6 %; clinicians should counsel patients on return precautions and consider observation protocols accordingly. 3

Head Injury Evaluation and Management

Immediate Emergency Department Evaluation Required

• The American College of Emergency Physicians recommends that any patient with a head injury should be evaluated immediately in an emergency department if they have any high-risk features, including loss of consciousness, amnesia, persistent headache, vomiting, age over 60-65 years, anticoagulant or antiplatelet use, neurologic deficits, signs of skull fracture, or dangerous mechanism of injury 5, 6, 7
• Patients with a GCS score less than 15 within 2 hours of injury require urgent ED assessment 5, 6, 7
• Any loss of consciousness or post-traumatic amnesia necessitates immediate ED evaluation 5, 6, 7
• Persistent or worsening headache is a high-risk feature requiring immediate ED evaluation 5, 6, 8
• Vomiting, especially if more than once, is a high-risk feature requiring immediate ED evaluation 5, 6, 7
• Age greater than 60-65 years is a high-risk feature requiring immediate ED evaluation 5, 6, 7
• Neurologic deficits, such as focal weakness, sensory changes, or abnormal mental status, require immediate ED evaluation 5, 6, 7
• Signs of basilar skull fracture, such as Battle's sign, raccoon eyes, hemotympanum, or CSF leak, require immediate ED evaluation 5, 6, 7
• Suspected open or depressed skull fracture requires immediate ED evaluation 5, 6, 7
• Post-traumatic seizure requires immediate ED evaluation 5, 6, 7
• Dangerous mechanism of injury, such as pedestrian struck by vehicle, fall from height, or high-speed motor vehicle collision, requires immediate ED evaluation 5, 6, 9

Medication-Related High Risk

• The American College of Emergency Physicians recommends that patients on any anticoagulant use, including warfarin, NOACs like apixaban, rivaroxaban, dabigatran, require immediate ED evaluation and CT imaging after any head trauma 10, 11
• Antiplatelet agents, such as clopidogrel or ticagrelor, excluding aspirin alone, require immediate ED evaluation and CT imaging after any head trauma 10, 11

Critical Timing Considerations

• Delayed intracranial hemorrhage can occur even with initially normal presentation, with a risk of 0.6-6% in patients on anticoagulants 10, 11, 12
• Patients who develop new or worsening symptoms after head injury require immediate ED evaluation, regardless of initial presentation 12, 8
• Worsening or persistent headache beyond 24 hours requires immediate ED evaluation 8
• New onset of vomiting or dizziness requires immediate ED evaluation 12
• Confusion or altered mental status requires immediate ED evaluation 8
• Focal neurologic deficits require immediate ED evaluation 12
• Increased sleepiness or difficulty arousing requires immediate ED evaluation 8
• Seizures require immediate ED evaluation 12

Special Population: Anticoagulated Patients

• All patients on anticoagulants or antiplatelet agents require immediate ED evaluation and CT imaging after any head trauma, regardless of how minor the mechanism appears 10, 11
• The risk of intracranial hemorrhage is 3.9% in warfarin patients vs 1.5% in non-anticoagulated patients 10
• NOACs have a 2.6% ICH rate vs 10.2% for vitamin K antagonists, but both are higher than non-anticoagulated patients 10, 11
• Bleeding progression occurs in 26% of anticoagulated patients vs 9% of non-anticoagulated patients 11

Imaging and Clinical Management of Mild Traumatic Brain Injury in Young Adults

Epidemiology of Mild TBI

• Mild traumatic brain injury (Glasgow Coma Scale 14‑15) accounts for more than 75 % of all head trauma presentations in young adults and may be present with or without detectable structural abnormalities on computed tomography (CT) scans. 13

Post‑Concussive Syndrome

• Approximately 58 % of individuals with mild TBI develop post‑concussive syndrome at one month, and 15 % continue to experience symptoms at one year; the syndrome is defined by persistence of headache, dizziness, cognitive deficits, or related symptoms beyond three months. 13

Imaging Modality Selection

• Non‑contrast head CT is recommended as the initial imaging study for acute closed head injury because it rapidly identifies surgically treatable lesions, skull fractures, and acute intracranial hemorrhage. 13
• Magnetic resonance imaging (MRI) should be pursued when CT does not explain ongoing neurological deficits, as MRI is more sensitive for detecting subtle cortical contusions, small subdural hematomas, and diffuse axonal injury (white‑matter shearing). 13

Advanced MRI Techniques

• Diffusion‑weighted MRI provides higher sensitivity than CT for the detection of acute ischemic stroke secondary to traumatic cerebral hypoperfusion. 13