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A traumatic head or brain injury results from the transmission of an external force to the skull and its content.



This force may be represented by different causes, e.g. traffic accidents, falls (particularly in elderly people), physical assaults, projectiles, etc.


Classification and grading  

Pathophysiologic grading

A first classification is considering the pathophysiologic process of damage, dividing primary and secondary brain injuries.

Primary injury

Refers to the damage, focal or diffuse, directly caused by the initial external force (direct impact, rapid acceleration or deceleration, penetrating object, blast waves, …)

Secondary injury

Refers to the damage caused indirectly by the trauma, as a consequence of the alteration of brain homeostasis (neurotransmitter release, free-radical generation, calcium-mediated damage, gene activation, mitochondrial dysfunction, and inflammatory responses).

The interaction of an external force with the structures within the brain may determine, leading to a worsening of the primary damage:

  • Oedema
  • Local hypoxia
  • Increased intracranial pressure
  • Inadequate perfusion pressure
  • ischemia

As the primary damage is considered, by definition, unavoidable, it is the real target of medical assistance to prevent or minimize the consequences of this indirect damage. It is important to remember that traumatic brain injury is a dynamic process.

Glasgow Coma Scale

A second assessment may be performed considering the neurological condition severity of the patient; post-resuscitation Glasgow Coma Scale score is the most widely used tool for this purpose; nevertheless, many criticisms have been moved toward this method, for not being a parametric, a linear scale or interval scale (i.e. a decrease of a certain number of points in one parameter is not equal to the same decrease in another) and for not providing information about the pathophysiologic mechanism of the neurological damage.

Glasgow Coma Scale score

Traumatic Brain Injury may be then classified as follows:

  • Minimal - GCS 15, no loss of consciousness, no amnesia
  • Mild - GCS 14 or GCS 15 and brief loss of consciousness (<5 min)
  • Moderate - GCS 9-13 or loss of consciousness >5 min or focal neurological deficit
  • Severe - GCS 5-8
  • Critical - GCS 3-4

GCS plays an important role in defining prognostic information. Patient with low post-resuscitation GCS (3-5) are more likely to have an eventual outcome of death or severe disability, with exitus in approximately 65% of patient with GCS 3.

Patient management

Caution should be taken with patient in which neurological assessment is impaired by different matters, such as intubation, sedation, pharmacologic paralysis, intoxication (care with traffic accidents in drunken people).

Anatomic severity grading

Traumatic injuries can also be assessed considering the anatomic structures affected, discerning contusions or lacerations of epicranial tissues, skull fractures, intracranial haemorrhages (epidural, subdural, subarachnoid, intraparenchymal, intraventricular), axonal injuries. 



Greenberg M. Handbook of neurosurgery. 7th ed. New York: Thieme; 2010.

Quinones-Hinojosa, Alfredo. Schmidek and Sweet: Operative Neurosurgical Techniques: Indications, Methods and Results (Expert Consult-Online and Print). Elsevier Health Sciences, 2012.

Head injury: assessment and early management. NICE guidelines [CG176] Published date: January 2014

Ghajar J. Traumatic brain injury. Lancet 2000; 356: 923–29.

Maas AI, Stocchetti N, Bullock R (August 2008). Moderate and severe traumatic brain injury in adults. Lancet Neurology. 7 (8): 728–41.

Saatman KE, Duhaime AC, et al. (2008). Classification of traumatic brain injury for targeted therapies. Journal of Neurotrauma. 25 (7): 719–38.




Antonio D'Ammando, MD

University of Milan (Italy)
"Spedali Civili" Hospital - Brescia (Italy)
Scientific Team UpSurgeOn


Giorgio Saraceno, MS

University of Brescia (Italy) 
Scientific Team UpSurgeOn