Brain injury

Brain injury

Introduction

Severe head injuries require immediate medical attention because there’s a risk of serious brain damage.

Signs of a severe head injury can include:

  • unconsciousness – either brief (concussion) or for a longer period of time
  • fits or seizures 
  • difficulty speaking or staying awake
  • problems with the senses such as hearing loss or double vision
  • repeated vomiting
  • blood or clear fluid coming from the ears or nose
  • memory loss (amnesia)

If you experience any of these symptoms after a head injury, go immediately to your nearest accident and emergency (A&E) department or call 999 and ask for an ambulance.

Read more about the symptoms of a severe head injury.

Diagnosing a severe head injury

Healthcare professionals use the Glasgow Coma Scale (GCS) to assess head injuries. This is a scale from 3 to 15 that identifies how serious your head injury is, based on your symptoms, and whether the brain has been damaged (with 3 being most severe and 15 least severe).

A head injury is usually classed as being moderate if someone has a GCS score of 9-12 or severe if they have a score of eight or lower. Some people with significant head injuries have a high GCS score initially, but their score decreases when they’re reassessed at a later stage.

Further tests, such as a computerised tomography (CT) scan, are sometimes needed to determine the seriousness of a head injury.

Read more about how severe head injuries are diagnosed.

Treating a severe head injury

Severe head injuries always require treatment in hospital. Hospital treatment may involve:

  • observing the condition for any changes
  • running tests to check for further damage
  • treating any other injuries
  • breathing support (ventilation) or brain surgery, in the most severe cases

Most people are able to go home within 48 hours. However, a small number of those admitted to hospital require skull or brain surgery.

When you’re discharged from hospital, your doctor will give you advice about the best way to help your recovery when you return home.

Read more about how a severe head injury is treated and recovering from a severe head injury.

Complications

A severe head injury may cause a build-up of pressure on the brain because of bleeding, blood clots or a build-up of fluid. This can sometimes lead to brain damage, which can be temporary or permanent.

A severe head injury can also cause other potentially serious complications including:

  • an infection after a skull fracture
  • post-concussion syndrome – where you experience long-term symptoms after sustaining concussion
  • impaired consciousness
  • brain injury

Around one in every 2,000 people who attend an A&E department with a head injury dies as a result of their injury.

Read more about complications after a severe head injury.

Preventing head injuries

It can be difficult to predict or avoid a head injury, but there are some things you can do to reduce the risk of serious injury to you or your child. These include:

  • reducing hazards in the home that may cause a fall
  • ‘childproofing’ your home
  • using the correct safety equipment for work, sport and DIY

Wearing a safety helmet during certain activities, such as skiing or cycling, may also help prevent a serious head injury.

Read more about how to prevent head injuries.

Symptoms of a severe head injury

If a severe head injury isn’t correctly treated, it can cause serious brain damage.

The signs of a severe head injury can include:

  • unconsciousness, either briefly or for a longer period of time
  • difficulty staying awake or still being sleepy several hours after the injury
  • clear fluid leaking from the nose or ears (this could be cerebrospinal fluid, which normally surrounds the brain)
  • bleeding from one or both ears
  • bruising behind one or both ears
  • any sign of skull damage or a penetrating head injury
  • difficulty speaking, such as slurred speech
  • difficulty understanding what people say
  • reading or writing problems
  • balance problems or difficulty walking
  • loss of power or sensation in part of the body, such as weakness or loss of feeling in an arm or leg
  • general weakness
  • vision problems, such as blurred or double vision
  • having a seizure or fit (when your body suddenly moves uncontrollably)
  • memory loss (amnesia), such as not being able to remember what happened before or after the injury
  • a persistent headache
  • vomiting since the injury
  • irritability or unusual behaviour

If any of these symptoms are present, particularly loss of consciousness (even for just a short time), go immediately to your local accident and emergency (A&E) department, or call 999 and ask for an ambulance.

You should also go to hospital if someone has injured their head and:

  • the injury was caused by a forceful blow to the head at speed, such as being hit by a car or falling one metre or more
  • the person has had previous brain surgery
  • the person has had previous problems with uncontrollable bleeding or a blood clotting disorder, or is taking medication that may cause bleeding problems, such as warfarin
  • the person is intoxicated by drugs or alcohol
  • it’s possible that the injury wasn’t accidental – for example, you deliberately hurt yourself or someone else hurt you on purpose

Also call 999 to ask for an ambulance if the person with the head injury isn’t breathing.

Read more about first aid and what to do after an incident.

Diagnosing a severe head injury

Someone with a severe head injury should always be seen in an emergency department.

If any of the symptoms of a severe head injury are present, immediately go to your local accident and emergency (A&E) department or call 999 and ask for an ambulance.

The healthcare professionals treating you will first make sure you’re in a stable condition, before asking some questions to help with the diagnosis and treatment of your injury. These may include:

  • how you were injured
  • when you were injured
  • whether you’ve been drinking alcohol
  • whether you’ve taken any illegal drugs

If you can’t remember how the injury occurred, they may ask someone who saw your accident to describe it.

You may also be asked about your symptoms, for example:

  • whether you’ve lost consciousness
  • whether you have a headache
  • whether you’ve been sick

If you’re with someone who has a head injury, try to provide as much information as possible about the accident and the person’s symptoms.

The paramedics or doctors treating you will assess your condition using the Glasgow Coma Scale (GCS), described below.

Glasgow Coma Scale

After a head injury, healthcare professionals use the Glasgow Coma Scale (GCS) to assess how severely your brain has been damaged. The GCS scores you on:

  • verbal responses (whether you can make any noise)
  • physical movements
  • how easily you can open your eyes

Your score for each of the three areas is added up to give a total. A slightly different version of the GCS is used for children under five years of age.

A score of 15 (the highest possible score) means that you know where and who you are, you can speak and move as instructed, and your eyes are open.

A score of three (the lowest possible score) means you can’t open your eyes, move or make a noise. The score indicates that your body is in a coma (a state of unconsciousness where a person is unresponsive and can’t be woken).

Depending on your score, head injuries are classed as:

  • minor – a score of 13 or higher
  • moderate – a score of nine to 12
  • severe – a score of eight or lower

Based on your assessment, you may be allowed to go home or you may be referred for further testing and treatment in hospital.

The brain injury association Headway has more detailed information about the Glasgow Coma Scale.

Going home

After a head injury, you’ll usually only be allowed to go home if the results of your assessment suggest you’re at low risk of brain injury and a CT scan isn’t deemed necessary.

You’ll need someone to take you home because you won’t be allowed to drive until you’ve completely recovered. If possible, you’ll also need someone to stay with you for the first 24 hours after your injury to keep an eye out for problems.

The healthcare professionals will advise you about what to do and what not to do in the weeks following your injury. Read about recovering from a head injury for more information about caring for a head injury at home. 

CT scan

Based on the results of their assessment, emergency department staff will decide whether you need to have a computerised tomography (CT) scan to determine how serious your head injury is and whether you’re at risk of developing any complications of a severe head injury.

During a CT scan, a series of X-rays are taken from different angles to produce a detailed image of the inside of your body. The scan can be used to examine the bone, muscle and tissue in your neck, check for damage, and identify whether there’s any bleeding or swelling in your brain.

Depending on the results of your scan, you may be allowed to go home. However, you’ll usually be kept in hospital for a short period of time to make certain that your injury hasn’t caused any serious problems.

Admission to hospital

Some people need to be admitted to hospital for observation following a head injury. This may be because:

  • scans have identified a problem
  • you have persistent symptoms of a possible neurological problem (a problem with the nervous system)
  • your GCS score hasn’t returned to 15
  • you have other injuries, such as broken bones, or health problems
  • you’re under the influence of alcohol or drugs
  • there’s no one at home to look after you

See how a severe head injury is treated for more information about what happens when you’re admitted to hospital.

Treating a severe head injury

A severe head injury must always be treated in hospital to minimise the risk of complications.

Initial treatment

When you arrive at the emergency department of a hospital, or before getting to hospital if you called an ambulance, the doctors or paramedics treating you will prioritise any injury that may be life threatening. This could mean:

  • checking your airway is clear
  • checking you’re breathing, and starting cardiopulmonary resuscitation (CPR or mouth-to-mouth) if you’re not
  • stabilising your neck and spine – for example, using a neck brace
  • stopping any severe bleeding
  • providing pain relief if you’re in a lot of pain
  • splinting any fractured or broken bones (strapping them into the correct position)

Once you’re stable, further treatment will be arranged, as necessary, including any tests you need to help determine the severity of your injury. Read about diagnosing a severe head injury for more information about tests you may have.

Observation

If you need to stay in hospital for observation, doctors and nurses treating you will check:

  • your level of consciousness and how alert you are
  • the size of your pupils, and how well they react to light
  • how well you can move your arms and legs
  • your breathing
  • your heart rate
  • your blood pressure
  • your temperature
  • the level of oxygen in your blood

These checks will be made every half an hour until it’s clear you know where and who you are, you can speak and move as instructed, and your eyes are open. After this, checks will be made less frequently.

Any changes in your condition or behaviour will also be closely monitored. If your condition worsens, you may need to have further tests, such as a computerised tomography (CT) scan

If there’s been any bleeding or swelling inside the skull, a small device called an intracranial pressure (ICP) monitor may be fitted. A thin wire will be inserted into the space between the skull and the brain, through a small hole drilled into the skull. The wire is attached to an electronic device that alerts hospital staff to any changes in the pressure inside your skull.

Cuts and grazes

If you have any external cuts or grazes to your head, they’ll be cleaned and treated to prevent further bleeding or infection. Any foreign bodies in the wound, such as broken glass, will need to be removed.

Deep or large cuts may require stitches (sutures) to keep them closed until they heal. Local anaesthetic may be used to numb the area around the cut so you don’t feel any pain.

Neurosurgery

Neurosurgery is any kind of surgery used to treat a problem with the nervous system (the brain, spinal cord and nerves). In cases of severe head injury, neurosurgery is usually carried out on the brain.

Possible reasons for neurosurgery include:

  • a haemorrhage – severe bleeding inside your head, such as a subarachnoid haemorrhage, which puts pressure on the brain and may result in brain injury and, in severe cases, death
  • a haematoma – a blood clot inside your head, such as a subdural haematoma, which can also put pressure on the brain
  • cerebral contusions – bruises on the brain, which can develop into blood clots
  • skull fracture (see below)

These conditions will be identified during tests, such as a CT scan, and a neurosurgeon (an expert in brain and nervous system surgery) may come and speak to you or your family about whether surgery is necessary.

As the above conditions can be serious and may require urgent treatment, in some cases there may not be time to discuss the surgery before it’s carried out. After the operation, your surgeon will take the time to discuss the details of the surgery with both you and your family.

Craniotomy

A craniotomy is one of the main types of surgical operation carried out to treat severe head injuries.

It involves making a hole in the skull so that the surgeon can access your brain. The procedure will be carried out under general anaesthetic, so you’ll be unconscious and won’t feel anything while it’s performed.

Once the surgeon is able to access your brain, they’ll remove any blood clots that may have formed and repair any damaged blood vessels. When any bleeding inside your brain has stopped, the piece of skull bone will be replaced. In many cases, the piece of skull is reattached using small metal screws.

Skull fractures

Your skull can fracture during an injury to your head. If this happens, you’ll usually have a CT scan to determine the extent of the injury.

There are different types of skull fractures, including:

  • simple (or closed) fracture – where the skin hasn’t broken and the surrounding tissue isn’t damaged
  • compound (or open) fracture where the skin has broken and the surrounding tissue may be damaged
  • linear fracture where the break in the bone looks like a straight line
  • depressed fracture where part of the skull is crushed inwards
  • basal fracture – a fracture to the base of the skull

Open fractures are often serious because there’s a higher risk of infection by bacteria if the skin is broken. Depressed fractures can also be very serious because small pieces of bone can press inwards against the brain.

Treating skull fractures

Most skull fractures will heal by themselves, particularly if they’re simple, linear fractures. The healing process can take many months, although any pain will usually disappear in around five to 10 days.

If the fracture is open, you may be prescribed antibiotics to prevent an infection.

If the fracture is severe or depressed, you may need surgery to help prevent any damage to the brain. This will usually be carried out under general anaesthetic.

During the operation, any pieces of bone that have been pressed inwards can be removed and returned to their correct position. If necessary, metal wire or mesh may be used to reconnect the pieces of your skull.

Once the bone is back in place, it should heal naturally. Your surgeon can explain the procedure you’re having in more detail.

After surgery

Depending on how serious your operation was, you may need to recover in an intensive care unit (ICU). This is a small, specialised ward where your condition will be constantly monitored. 

In an ICU, you may be placed on a ventilator, which is an artificial breathing machine that moves oxygen-enriched air in and out of your lungs.

Once you’re well enough, you’ll be moved to a high-dependency unit (HDU) or another ward and your condition will continue to be observed (see above) until you’re well enough to leave hospital.

Read more about recovering from a severe head injury.

Recovering from a severe head injury

When you’re discharged from hospital, your doctor will give you advice to help your recovery at home.

Your recovery programme will depend on the exact nature of your injury and your individual needs.

Advice for adults

If you’re recovering from a severe head injury you may be advised to:

  • have someone stay with you for the first 24 hours and keep within easy reach of a phone in case any problems arise and you need medical help
  • get plenty of rest and avoid stressful situations
  • avoid drinking alcohol or taking recreational drugs
  • avoid taking sleeping pills, sedatives or tranquilizers (unless prescribed by your doctor)
  • take paracetamol if you have a headache, but avoid non-steroidal anti-inflammatory drug (NSAIDs), such as ibuprofen and aspirin (unless prescribed by a doctor)
  • avoid playing contact sports, such as football or rugby, for at least three weeks, and speak to your doctor before starting to play these sports again
  • not return to work or school until you’ve completely recovered and feel well enough to do so
  • not drive a car or motorbike, ride a bicycle or operate machinery until you feel completely recovered and it’s safe and legal to do so

When to seek medical attention

You should seek immediate medical attention if you develop any further symptoms of a severe head injury while recovering at home.

Advice for children

If your child is recovering from a severe head injury you may be advised to:

  • give them paracetamol if they have a headache, but avoid NSAIDs, such as ibuprofen and aspirin (aspirin should never be given to children under 16 years of age)
  • only give them light meals for the first day or two
  • avoid getting them too excited
  • avoid having too many visitors when they return home
  • not let them play contact sports until a doctor advises that it’s safe to do so
  • not let them play roughly for a few days

When to seek medical attention

Seek immediate medical attention if your child develops any further symptoms of a severe head injury while recovering at home. 

Follow-up appointments and rehabilitation

You should see your GP the week after being discharged from hospital so they can check how you’re coping after your head injury.

You may also need to attend one or more hospital appointments. These will usually be with a specialist, such as a neurologist (an expert in the brain and nervous system). They’ll check on the progress of your recovery.

The speed at which you recover from a severe head injury will depend entirely on the severity and nature of your injury, as well as your individual needs and your general health. Don’t rush your recovery. It may take several months, or sometimes years, before you feel fully recovered.

After a head injury, a number of different healthcare professionals may help with your recovery. The treatment you receive will depend on how your head injury has affected you. Some of the treatments and the healthcare professionals you may see are discussed below.

Physiotherapy

Physiotherapy helps restore movement and function when someone is affected by injury, illness or disability.

If you experience physical problems after your injury, such as weakness, stiffness or poor co-ordination, you may be referred to a physiotherapist.

A physiotherapist uses a variety of treatment techniques, such as massage, exercise and hydrotherapy (special exercises in warm, shallow water) to help you recover physically.

Occupational therapy

The aim of occupational therapy is to help you live as independently as possible.

After a head injury, you may struggle with everyday tasks and activities, either at work or home. An occupational therapist can provide practical support to make those tasks easier.

Speech therapy

A head injury can sometimes affect your speech and you may struggle to communicate in the same way you did before the injury. A speech therapist will help you regain your communication skills.

Psychotherapy and CBT

After a severe head injury, you may have problems adjusting back to everyday life.

Psychotherapy is a type of therapy where you talk about your thoughts and feelings with a trained mental health professional.

They’ll help you talk through your worries and problems so that you can better understand and deal with your thoughts and feelings.

Cognitive behavioural therapy (CBT) is another type of talking therapy that may be recommended. CBT helps change the way you think about things so that you deal with problems more positively and effectively.

Psychiatry

Psychiatry is a medical field concerned with the diagnosis, treatment and prevention of mental health conditions. Psychiatrists are medically qualified doctors who have chosen to specialise in psychiatry. This means they can prescribe medication as well as recommending other forms of treatment.

Getting support

Headway, the brain injury association, is a charity that provides help and support to people affected by head injuries.

For more information about all aspects of head injuries, call the Headway helpline on 0808 800 2244. You can also email the helpline: helpline@headway.org.uk

Helpline staff can:

  • give you support and advice if you experience problems
  • help you find local rehabilitation services
  • advise you about other sources of support

The Headway website has a post code search that you can use to search for local Headway services. They offer a wide range of services, including rehabilitation programmes, carer support, social re-integration, community outreach and respite care (when short-term support is provided for someone who needs care – for example, to give the usual carers a break.)

Staff at Headway can’t give medical advice or a diagnosis. For this, see your GP or call NHS 111.

Complications of a severe head injury

Severe head injuries can cause serious complications. This is mainly because a serious injury can damage the brain, sometimes permanently.

In particularly severe cases, a serious head injury can be fatal. People with these type of injuries are closely monitored when they’re admitted to hospital to ensure any complications that arise are dealt with promptly and effectively.

Infection

If your skull is fractured during a head injury, your risk of developing an infection may be increased. Skull fractures can occasionally tear the membrane (the thin layer of cells) that surrounds the brain. If this happens, bacteria can enter the wound and cause an infection.

It’s important to keep any external wounds on your head clean so they don’t become infected. You may also be prescribed antibiotics.

Post-concussion syndrome

Some people may experience long-term symptoms after sustaining concussion from a head injury. This could be post-concussion syndrome.

Symptoms of post-concussion syndrome can include:

  • having trouble looking after yourself
  • not being able to work
  • a persistent headache
  • dizziness
  • feeling weak
  • tinnitus (hearing sounds that come from inside the body, rather than from an outside source)
  • nausea (feeling sick)
  • trouble sleeping and fatigue (extreme tiredness)
  • memory problems 
  • problems understanding other people
  • poor concentration

These symptoms usually clear up in around three months but, if necessary, you may need to be referred for further assessment by your GP. You may be seen by a neurologist, who specialises in problems of the nervous system (brain, spinal cord and nerves), or a psychiatrist (a mental health specialist).

Read more about post-concussion syndrome.

Impaired consciousness

Some people who sustain a severe head injury enter a state of impaired consciousness, such as a coma, vegetative state or minimally conscious state.

These disorders of consciousness affect wakefulness (the ability to open your eyes and have basic reflexes) and awareness (more complex thoughts and actions, such as following instructions, remembering and communicating).

These states sometimes only last a few weeks, after which time a person may wake up or progress into a different state of impaired consciousness. However, they can last years and some people will never regain consciousness.

If a person is in a state of impaired consciousness for a long time, usually at least a year, it may be recommended that nutritional support is withdrawn because there’s almost no chance of a recovery by this point.

If agreement is reached about withdrawing life support, the decision has to be referred to the courts in England and Wales before any further action can be taken.

Read more about treating disorders of consciousness.

Brain injury

A severe head injury can damage the brain in several ways. For example, brain damage can occur as a result of increased pressure on the brain caused by a blood clot between the skull and the surface of the brain (subdural haematoma), or bleeding in and around the brain (subarachnoid haemorrhage).

Injuries to the brain can lead to a variety of problems. Some types of brain injury are only temporary, whereas others result in permanent damage. The effect of any brain injury will depend on:

  • whereabouts on the head the injury occurs
  • the type of injury – for example, if the skull is fractured
  • the severity of the injury – for example, if it requires surgery

The different effects of a brain injury are described below.

Physical effects

Physical effects of a brain injury can include difficulty moving or keeping your balance and loss of co-ordination. You may also experience headaches or increased tiredness. 

Hormonal effects

Some head injuries can damage the pituitary gland. The pituitary gland is a pea-sized gland in the centre of the head. It hangs below the brain and produces hormones (powerful chemicals that have a wide range of effects on the body). If the pituitary gland is damaged, it may lead to a reduction in the production of hormones.

Sensory effects

Your senses may be affected by a brain injury. For example, you may lose your sense of taste or smell. You may also notice blind spots in your vision or you may not be able to control your body temperature as well as before, so that you feel too hot or too cold.

Cognitive effects

Following a head injury, your ability to think, process information and solve problems may be affected. You may also experience memory problems, particularly with your short-term memory, and have difficulty with speech and communication skills.

Emotional or behavioural effects

After a severe head injury, you may experience changes to your feelings and behaviour. For example, you may have feelings of irritation, anger or selfishness.

You may be less sensitive to other people’s feelings, or lose your inhibitions and behave in a way other people may consider inappropriate. You may also laugh or cry more than you did before the injury.

Getting support

As every brain injury is different, it’s a good idea to seek further information about the possible effects and rehabilitation techniques. A number of charities and organisations may be able to help, including:

Preventing a severe head injury

Many head injuries are the result of accidents that are difficult to predict or avoid. However, there are some ways to reduce your risk.

Safety helmets

Cyclists and motorcyclists can protect their head by wearing a properly fitting safety helmet. British Standard safety helmets are a legal requirement for motorcyclists.

Research commissioned by the Department for Transport found that bicycle helmets ‘should be effective at reducing the risk of head injury’.

However, it’s difficult to be certain about the benefits of cycle helmets. This is because data about road accidents that involve cyclists may not contain all of the relevant information. For example, the data may not explain where exactly the head injury occurred, which makes it difficult to determine whether a helmet might have prevented the injury.

The National Institute for Health and Care Excellence (NICE), the Royal Society for the Prevention of Accidents (RoSPA) and the World Health Organization (WHO) all support the use of cycle helmets and suggest that they may help to reduce head injuries.

As well as wearing a helmet when cycling, you should also make sure that both you and your children:

  • use lights and wear reflective clothing when cycling in the dark
  • are aware of the dangers of the road and know how to stay safe
  • always follow the Highway Code (GOV.UK has an online version of the Highway Code)
  • check that the bike is in good working order

Read more cycling safety advice.

Safety in the home

Following sensible health and safety guidelines can help prevent accidents in the home. To help keep your home and garden as safe as possible you should:

  • keep stairways tidy so that you don’t trip over anything
  • use appropriate safety equipment if you’re doing any kind of DIY
  • don’t stand on an unstable chair to change a light bulb – use a stepladder
  • clean up any spillages to prevent someone slipping over

See the RoSPA website for more information.

Childproofing your home

It’s not possible to childproof your home completely. However, you can take steps to keep toddlers and young children safe at home. For example, you can:

  • check that windows are lockable and can’t be opened by your child, particularly bedroom windows
  • move furniture, such as beds, sofas and chairs away from windows to prevent your child climbing up and falling out
  • fit safety gates at the top and bottom of the stairs

Read more about preventing accidents to children in the home and teaching your child to stay safe.

Safety at work

To reduce the risk of sustaining a head injury at work, always follow any necessary health and safety guidelines. For example, you may have to wear a hard hat when working in potentially hazardous areas.

Only use ladders in a workplace environment for short-term, light work. Any work that requires spending a considerable amount of time at height, or involves heavy lifting, should be carried out on scaffolding or another suitable platform.

The Health and Safety Executive (HSE) provides more information about the correct use of ladders in the workplace, including a list of common tasks that involve working at height.

Any work that involves going up onto a roof should also be considered high-risk and therefore high standards of safety are essential.

Read more about carrying out minor roof work, including tips for safe working.

Sport safety

Wear any necessary safety equipment when playing sports, particularly contact sports. Don’t play any contact sports after a head injury without first consulting your GP.