Traumatic Brain Injury (TBI) (Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • All NHS Highland
  • Primary and Secondary care
  • Adults and children

No decisions regarding severity should be based on one indicator alone; LOC is a particularly unreliable indicator of severity

Brain Injury Severity

Mild

Moderate

Severe

LOC

 < 30 minutes ≥ 30 minutes
≤ 24 hours		 > 24 hours

PTA

 ≤ 24 hours 1 to 6 days > 7 days (more than 4 weeks = very severe)

GCS

 13 to 15 9 to 12 ≤ 8

Symptoms

 Blurred vision, ringing in ears, bad taste in mouth, change in ability to smell, confusion, dazed, dizziness or loss of balance, headache, nausea, fatigue or drowsiness, problems with speech, focal neurological symptoms, memory or concentration problems, mood changes / swings, feeling anxious or depressed, difficulty sleeping or sleeping more than usual Persistent headache / headache that worsens, repeated vomiting or nausea, convulsions or seizures, dilation of one or both pupils, clear fluids draining from nose or ears, inability to waken from sleep, weakness or numbness in fingers and toes, loss of coordination, profound confusion, agitation / aggression, slurred speech, apathy (more common in severe presentations)

Injury data from scans (MRI< CT< DAT)

 Possible skull fracture,
axonal damage possible but likely not as diffuse as in moderate to severe cases (more diffuse injuries in this category linked with > length of recovery)		 Skull fracture, Haematoma (epidural or subdural), contusions, penetrating TBI, haemorrhage, brain stem
injury (more common in severe presentations), Diffuse axonal injuries, secondary injuries (e.g., hypoxia, increased ICP, seizures, etc.)

Cognitive screening

 May show mild selective deficits Will show selective deficits across a number of domains on neuro-psychological assessment

Average Length of Neuropsych Recovery

 3 to 6 months (subset of this category may have longer term deficits)

6 months or longer, ¼ fail to return to work after a year

More severe injuries can take 2 to 5 years with some never reaching full recovery

NOTE: TBI patients may fall below cut-off scores of cognitive screening tools such as the MoCA and ACE-III/R and they may be used more effectively as qualitative assessments of possible domain deficits (de Guise et al.,
2014; Gaber, 2008). Deficits are more likely to occur in executive functioning, attention, and orientation than naming, language and abstraction (de Guise et al., 2014)

Glasgow Coma Scale

Eye opening (E)

 Verbal response (V) Motor response (M)
4: spontaneous eyes open, not necessarily
aware		 5: oriented converses and oriented 6: obeys commands follows simple commands
3: to speech non-specific response, not
necessarily to command		 4: confused converses but confused,
disoriented		 5: localises to pain arm attempts to remove
supra-orbital/chest pressure
2: to pain from sternum/ limb/ supraorbital pressure 3: inappropriate words intelligible, no sustained
sentences		 4: withdrawal arm withdraws to pain,
shoulder abducts
1: none even to supra-orbital
pressure		 2: incomprehensible sounds moans/groans, no speech 3: flexor response withdrawal response or
assumption of hemiplegic
posture
    1: none no verbalisation of any
type		 2: extension shoulder abducted and
forearm internally rotated
        1: none shoulder abducted and
forearm internally rotated
Total + E + V + M

Glasgow Coma Scale (GCS) (Teasdale & Jennett, 1974) 

Further Guidance on Imaging

CT classification systems have been devised to assess the severity of TBI and make predictions of mortality. The Marshall and Rotterdam CT classification systems have both been evidenced to be good predictor of mortality based on scans at admission (Asim et al., 2021). There does not appear to be any research to determine what cut-offs can be used to determine mild, moderate or severe as in the table above however, a higher score is related to more severe injuries. Injuries considered and scoring systems can be found below:

Rotterdam CT Score

Injury

 Score
Basal cisterns

0 = Normal

1 = Compressed

2 = Absent
Midline shift

0 = no shifts or <5mm

1 = shift >5mm
Epidural Mass Legion

0 = present

1 = absent
Intraventricular blood or traumatic SAH

0 = absent

1 = present

Scoring = Sum the scores to all items then +1 (worst score = 6)
Prognosis in adults = mortality at 6 months increases with score:

Score 1 = 0% 
Score 2 = 7%
Score 3 = 16%
Score 4 = 26%
Score 5 = 53%
Score 6 = 61%

Marshall CT Classification System

Injury

 Score
No visible intracranial pathology  1
Cisterns are present: no high or mixed density lesion >25ml includes bone fragments or foreign bodies 2
Cisterns compressed or absent with 0-5mm midline shift; no high- or mixed-density lesion >25ml 3
Midline shift >5mm; no high- or mixed-density lesion >25ml 4
Any lesion surgically evacuated 5
High- or mixed-density lesion >25ml; not surgically evacuated 6

Clinical features of brain imaging and their associated risk of long-term neuropsychological impairment

Baxendale et al. (2019) has also attempted to classify by clinical neuroimaging features by their associated likelihood of neuropsychological recovery:

Possibility Long-Term Impairments Some possibility Long-Term Impairments 

Incomplete Neuropsychological Recovery Likely 
Abnormalities suggestive of
traumatic axonal injuries evident in
DTI
  • May be associated with processing speed or focal deficits
  • Can also be resent with no neuropsychological correlates
 Evidence of inflammatory response Evidence of diffuse axonal injury on
MRI
  • More widespread injury = more widespread cognitive deficit
Evidence of contusions
  • Particularly if damage remains evident on later scans
 Presence of midline shift

Anoxia

  • Depends on length of time and severity
Evidence of sulcal effacement
  • Duration and extent = important determinant

Elevated intracranial pressure

  • More elevated and longer duration = higher risk
 Presence of ischaemic brain injury
 

 

 Surgical intervention required
 

 

 Prolonged PTA (> 1 week) 
 

 

 Intraventricular haemorrhage

Abbreviations

  • CT: computed tomography scan
  • DAT: Dopamine active transporter scan
  • DTI: Diffusion Tensor Imaging 
  • GCS: Glasgow Coma Scale
  • ICP: Intracranial Pressure
  • LOC: Loss of Consciousness
  • MoCA: Montreal Cognitive Assessment 
  • MRI: Magnetic resonance imaging
  • PTA: Post-Traumatic Amnesia
  • TBI: Traumatic brain injury

Editorial Information

Last reviewed: 30/10/2025

Next review date: 30/10/2028

Author(s): Neuropsychology Department.

Version: 1

Approved By: TAM subgroup of the ADTC

Reviewer name(s): E Neilson, Clinical Psychologist.

Document Id: TAM716

References
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    811. URL
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