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Mild traumatic brain injury

Last updated: February 25, 2021

Summarytoggle arrow icon

Mild traumatic brain injury (mTBI) is a trauma-induced disruption of brain function on the lowest end of the TBI severity spectrum, typically due to falls, motor vehicle accidents, and sports injuries. Characteristic manifestations include a GCS ≥ 13–15, transient loss of consciousness, altered mental status at the time of injury, posttraumatic amnesia, and minor neurological abnormalities that do not require surgical intervention. Concussion, a term often used synonymously with mTBI, is difficult to define but typically refers to a heterogeneous subset of TBI with variable constellations of physical, cognitive, and neuropsychiatric features and variable recovery times. mTBI is primarily a clinical diagnosis. Neuroimaging is not routinely indicated, as it is frequently normal or reveals only minor findings that do not alter management. Clinical decision rules for neuroimaging should be used to identify patients at risk of intracranial lesions that require surgical intervention. Most patients with a reassuring clinical presentation can be treated as outpatients after a period of observation, while some benefit from hospital admission and monitoring. If at any point during the observation period the GCS deteriorates to < 13, the patient should be reclassified as moderate TBI or severe TBI and managed accordingly. The mainstay of treatment of mTBI is physical and cognitive rest until patients are completely asymptomatic, followed by a gradual return to activity. Most patients recover completely within 1–2 weeks and better outcomes are associated with early diagnosis and treatment adherence. Postconcussion syndrome is the most common complication, causing symptoms lasting for weeks to months that usually require multidisciplinary care and follow-up.

See also “Traumatic brain injury” for information on moderate and severe TBI.

Background

  • There is a lack of consensus on the ideal terminology used to describe this entity.
  • “Mild traumatic brain injury” (mTBI) is the preferred term of most specialists and guideline working groups , however, its precise definition remains debated. [1][2][3]
  • Significant controversy surrounds the use of the terms “concussion” and “minor head injury”, as they are even more elusive to define and lack specificity. [4]
    • Several authorities have proposed to retire these terms in favor of “mTBI”. [3][5]
    • Nevertheless, “concussion” remains widely used in the literature [4][6][7][8]
    • Many authors and institutions use “concussion” interchangeably with “mTBI” despite ambiguities and variability in their definitions. [9][10]

Terminology

The working definitions provided here are based on the best available evidence and may change as this is an evolving area of research. [1][2][11][12]

  • Mild traumatic brain injury consists of a trauma-induced disruption of brain function associated with: [3]
    • GCS ≥ 13–15 at least 30 minutes after the injury
    • AND ≥ 1 of the following:
  • Concussion: A heterogeneous subset of mTBI associated with complex pathophysiology, and variable clinical features and natural history [4][8]
    • Symptoms should not be better explained by other injuries , toxic exposures , or comorbidities . [8]
    • Typically associated with no visible abnormalities on standard neuroimaging (i.e., CT, MRI) [5][9]
    • Can be categorized into the following concussion subtypes: [7]
      • Pain (e.g., headache, migraine)
      • Cognitive (e.g., impaired learning and memory)
      • Ocular or motor (e.g., delayed reaction time)
      • Vestibular (e.g., impaired balance)
      • Psychiatric (e.g., mood disturbances, anxiety)
    • Can be associated with sleep disturbance and/or cervical strain [7]
  • Incidence: mTBI accounts for approx. 75–90% of the estimated 1.7–2.5 million annual TBI cases. [11][13][14][15]
  • Sex: > [15][16][17]
  • Age: more common in children 0–4 years, teenagers and young adults 15–24 years, and adults > 65 years [18]
  • Occupation: more common in athletes and military populations. [16][19]

Epidemiological data refers to the US, unless otherwise specified.

  • Motor vehicle accidents [13][20]
  • Falls [21]
  • Sports-related injuries [17]
  • Assault
  • Struck by or against objects
  • Coup-contrecoup injury [1]

The pathophysiology of mTBI is complex and poorly understood. It is most likely an interplay of the following mechanisms of brain injury: [22]

Common clinical features [4][11][14][23]

  • Prerequisite: GCS ≥ 13–15
  • Variable onset, severity, and duration. [24][25]
  • Most common symptoms: confusion and amnesia
  • Can be associated with features of whiplash injury
Clinical features of mTBI
Domain Signs and symptoms
Physical
Cognitive
Behavioral (emotional)
Sleep

Symptoms of mTBI may be transient or subtle and should be explicitly asked about to avoid missing the diagnosis. [23]

Loss of consciousness at the time of injury is not required for the diagnosis, and its absence does not rule out mTBI. [23]

Red flags in mTBI [27][28][29]

The following features should raise the suspicion for undiagnosed moderate TBI or severe TBI, or a complication of mTBI that requires further evaluation and neuroimaging.

  • Anisocoria
  • History of prolonged loss of consciousness
  • Focal neurological signs: e.g., sensory, motor, speech, balance, or vision disturbances
  • Altered behavior: e.g., agitation, aggression without provocation, restlessness
  • Progression of any physical, cognitive, or behavioral symptoms, including:
    • Neurological decline: e.g., excessive drowsiness, somnolence, falling GCS score
    • Persistent or worsening headache
    • Intractable nausea or vomiting
    • Recurrent or intractable seizures
  • Inability to recognize family or friends
  • Current anticoagulant use

All patients with suspected mTBI with or without loss of consciousness should be evaluated as early as possible by a trained clinician. Patients with an initially high GCS score can deteriorate rapidly if there is a significant intracranial lesion. Initial management of mTBI should be performed with the same urgency as patients with moderate TBI or severe TBI until the patient is stable and shows neurological improvement. [9][23]

Primary survey

In stable patients with suspected mTBI and no obvious significant additional injuries, there typically is little need for intervention during the primary survey.

Patients who have a loss of consciousness > 30 minutes, posttraumatic amnesia > 24 hours, or evidence of intracranial hemorrhage on neuroimaging likely have a more severe brain injury (see ''Management of moderate or severe TBI'' for details).

Secondary survey

  • Detailed history
    • Obtain collateral information from witnesses.
    • Consider quantifying mTBI symptom number and severity using standardized assessment tools, e.g., acute concussion evaluation patient assessment tool [33]
    • Assess occupational risk (e.g., athletes, military personnel) of subsequent mTBI.
    • Identify lifestyle factors that may impact recovery (e.g., drug and alcohol consumption).
  • Physical examination
  • Monitoring
  • Further care and disposition: See "Treatment".

If at any point the GCS deteriorates below 13, reclassify the patient as moderate TBI (GCS 9–12) or severe TBI (GCS ≤ 8) and manage accordingly (see "Treatment of moderate or severe TBI" for details). [23]

Approach [9][23]

Clinical decision rules (CDRs) for neuroimaging in mTBI [10]

The following CDRs are not applicable to pediatric patients. The choice of CDR varies by institution and guidelines; both have been validated for clinical use. [35]

Criteria for neuroimaging in mTBI
CDR Criteria for neuroimaging: ≥ 1 of the following Inclusion criteria: all of the following

Canadian CT head rule (CCHR) [36][37]

New Orleans criteria [38]

The Canadian CT head rule is used for patients with an initial GCS of 13–15 with or without neurological deficits at presentation. The New Orleans criteria can only be used for patients with an initial GCS of 15 and no neurological deficits at presentation.

Alcohol and substance use alters the GCS score and neurological examination. Intoxication is considered a risk factor for traumatic intracranial lesion (according to the New Orleans Criteria). [23]

Neuroimaging findings [23][39]

Laboratory studies [9][23]

The following conditions may mimic mTBI (e.g., cause confusion and amnesia), but may also be the underlying precipitant of the injury that caused the mTBI. Careful clinical correlation and evaluation of the individual's pretest probability are recommended. [23]

Therapeutic measures for all patients [9][13][23][44][45]

After the initial management of mTBI, most patients only require rest and supportive therapy. See ''Special patient groups'' for additional considerations in patients on antithrombotic therapy.

  • Physical and cognitive rest: mainstay of therapy
    • Patients should refrain from strenuous mental and physical work or activity.
    • Individuals with suspected mTBI in the field (e.g., sporting events) should be immediately removed from activity, evaluated by a trained clinician, and not be allowed to return on the same day. [46]
  • Supportive pharmacological therapy: should be used for as short a duration as possible as some medications can potentially worsen postconcussion syndrome. [47]
  • Nonpharmacological therapy

Medications that can mask the symptoms of concussion (e.g., sedative-hypnotics) should be avoided. [24]

Disposition [9][10][23][45]

These criteria are not strict and clinical judgment and local resources should be considered for individual disposition decisions.

  • Outpatient management after an initial period of observation is safe in most patients with the following characteristics:
    • Clinical presentation: asymptomatic OR only mildly symptomatic
    • Neuroimaging: normal OR not performed as criteria for neuroimaging in mTBI were not met
    • Normal examination after the initial period of observation
    • Absent criteria for hospital admission
  • Hospital admission is suggested if any of the following are present:

Most patients with reassuring clinical features and either no neuroimaging (i.e., did not meet criteria for neuroimaging in mTBI) or normal neuroimaging can be managed safely as outpatients after an initial period of observation. [10]

  • Duration of rest [24]
    • Cognitive rest: minimum 24–48 hours
    • Physical rest
      • Nonphysical occupation: minimum 24–48 hours
      • Physically demanding occupation: Consider a longer duration (e.g., 5–7 days).
  • Discharge instructions
    • Provide written instructions for home care.
    • Advise returning to seek care if any red flags for mTBI develop [23]
    • Inform the patient and caregivers about risks of complications, e.g., postconcussion syndrome.
  • Referrals [45]
    • Neurosurgical consultation is not routinely required.
    • Follow-up with primary care provider within 1–2 weeks is reasonable.
    • Referral to specialized multidisciplinary neurotrauma teams is recommended for complex or refractory cases.

Return to activity [23][46][50][51]

  • Should only be considered once the patient is completely asymptomatic at rest
  • Adjust stepwise and gradual return to regular physical and cognitive activity according to symptoms
  • If a level of activity exacerbates symptoms, patients should remain on a lower tier of intensity until they are asymptomatic again.
  • Return to competitive sport is recommended only once the patient is asymptomatic on controlled moderate-severe physical activity.
  • Premature return to competitive sport is thought to increase the risk of second-impact syndrome (See “Complications”). [52][53]

Short hospital admission is typically recommended for patients with disabling symptoms, high-risk injuries, or other patient and system factors that render outpatient management unsafe. [9]

  • Monitoring and referrals
  • Follow-up neuroimaging (e.g., in 8–24 hours) should be considered in the following situations: [54]
    • Any signs of neurological deterioration (or other red flags for mTBI) during observation period
    • Neurological findings unexplained by initial neuroimaging
    • Evidence of intracranial injury on initial neuroimaging [23][55][56]
  • Treatment of complications
    • Anticonvulsant therapy for posttraumatic seizures [23]
    • Management of traumatic intracranial lesions (see ''Treatment'' sections in “EDH”, “SDH”, “SAH”, “ICH”).

Follow-up neuroimaging is not routinely required for patients with normal findings on both neurological examination and initial neuroimaging.

Patients on antithrombotic therapy [9][23][57][58]

Management of mTBI in patients on anticoagulant and/or antiplatelet medication is a challenge due to the risk of immediate and delayed intracranial hemorrhage (DICH) . There is a paucity of evidence on the optimal management of these patients.

Patients with bleeding disorders [63]

Patients with inherited bleeding disorders, e.g., hemophilia, should receive:

  • Most (80–90%) patients make a full recovery within 1–2 weeks. [23][24]
  • Outcomes are improved with early diagnosis and adherence to treatment. [45]

Immediate complications [9][23][34]

  • Posttraumatic seizures: uncommon [23]
  • Intracranial bleeding (e.g., ICH, SDH): uncommon
    • Abnormalities on initial CT are seen in approx. 5% of mTBI patients with GCS of 15 and 30% of mTBI patients with GCS of 13.
    • < 1% of mTBI patients require neurosurgical intervention.

Postconcussion syndrome (PCS) [6][14][51][64][65]

  • Epidemiology most common consequence of mTBI
  • Definition: a complex of cognitive, emotional, or sensorimotor symptoms secondary to mTBI
  • Clinical features: Symptoms are highly variable and often subjective.
    • Cognitive: difficulty in concentration, poor memory
    • Psychiatric: irritation, aggression, anxiety, depression, apathy, and reduced tolerance to stress, alcohol, and emotional excitement
    • Somatic: chronic headaches, easy fatigability, vertigo
    • Sleep disorders
  • Diagnostics [66]
    • Diagnosis is primarily clinical
    • Consider neuroimaging in patients with intractable or disabling symptoms.
  • Treatment [47]
  • Prognosis: Most patients recover within 6 months.

Other delayed complications [23]

  • Second-impact syndrome (SIS)
    • A very rare, but potentially devastating brain injury precipitated by a second injury that occurs prior to complete healing from an initial mTBI. [8][53][67]
    • Postulated pathomechanism: reinjury to susceptible brain cells with incomplete recovery→ rapid development of diffuse cerebral edema→ ↑ ICPbrain herniationdeath. [52]
  • Chronic traumatic encephalopathy [23]
    • A condition of cumulative neuropsychologic symptoms attributed to repeated TBI (e.g., from sports-related mTBI, military trauma).
    • Seen more commonly in professional athletes engaging in contact sports (e.g., boxing, football, hockey)
  • Other neurodegenerative diseases (e.g., Alzheimer disease, Parkinson disease): Patients with mTBI have an increased long-term risk of developing these conditions. [23]

We list the most important complications. The selection is not exhaustive.

References: [9][23][68][69]

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