Head injury and bleeding in the brain

What is this page about?

A head injury ranges from a small knock to serious brain injury. Traumatic brain injury is a disruption of the normal function of the brain caused by a blow, a violent jolt, or an object going through the skull. Most injuries are mild and get better, but some cause bleeding inside the skull, which can be an emergency. The most important thing is to know the warning signs.

Signs that mean emergency, straight away

In these situations call 115 at once (115 is Iran’s emergency number) and do not drive yourself. If, after a blow to the head, the person:

• lost consciousness and has not come round, or cannot stay awake with their eyes open
• has had a seizure
• fell from more than about a metre, or about five stairs
• has problems with vision or hearing
• has clear fluid or blood coming from the ear or nose, or bruising behind the ear
• has a black eye, but did not hit their eye
• has new numbness or weakness anywhere in the body
• has trouble walking, with balance, understanding, speaking or writing
• was hit at high speed, such as in a car crash
• has a head wound with something stuck in it, or a dent in the skull
• behaves differently, for example is irritable, distracted or uninterested in their surroundings
• is being sick (vomiting)
• has a condition that thins the blood, or takes medicine that thins the blood
• is under 1 year old and has a bruise, swelling or a large cut on the head

If you are in doubt or not sure, do not hesitate. Get help.

Be checked the same day if after the blow there is dizziness, alcohol or drugs at the time of the injury, or any other worry. A severe headache that does not ease with painkillers, confusion and memory loss also need checking the same day.

Types of injury

• Concussion. This is a temporary disturbance of brain function caused by a blow or violent shaking of the head. The patient does not have to lose consciousness. Symptoms include headache, confusion, dizziness, nausea, blurred vision, sensitivity to light and trouble concentrating.
• Haematoma (bleeding inside the skull). A blood clot inside the brain or on its surface. An epidural haematoma lies between the dura (the tough covering) and the skull bone, and a subdural haematoma lies between the dura and the surface of the brain. A haematoma can grow over hours to days after the injury.
• Contusion (bruise of the brain). A bruise of the brain tissue itself.

Who is this page for?

This page is for:

• someone who has hit their head and does not know whether it is serious
• a patient who had a CT in the emergency department and was told about bleeding or a contusion
• the family of a patient who is under observation or admitted after a blow
• people who take blood thinners, because they need faster assessment after a blow

Diagnosis

The heart and lungs are checked first, then a general and neurological examination, including alertness, how the pupils react to light, and brainstem reflexes. A CT scan is the standard test because it is fast and shows blood and fractures well. An MRI, once the patient is stable, may show injuries that did not show on the CT. Routine use of plain skull X-rays has become less common.

Treatment

• Observation. Many injuries only need to be watched. With more serious injuries, the patient is admitted to intensive care because lesions may get bigger. Intensive care focuses on preventing secondary injury, such as low blood pressure, raised pressure inside the skull, low oxygen, fever or high blood sugar.
• Surgery. Most haematomas need an operation. There are two general methods: temporarily removing part of the skull and putting it back, or making a few small holes in the skull (burr holes) to drain the blood. Some patients go from the emergency department straight to the operating theatre and others after a few days, if the examination gets worse, the pressure inside the skull rises, or a CT shows the lesion is growing.
• Severe brain swelling. Sometimes the bone that was removed is not put back for several weeks.

No medicine yet can prevent or repair nerve damage after an injury. This page does not say in which hospital or by what method an operation is done; the surgeon explains after seeing your images.

Recovery

• Mild concussion. Most people recover fully and quickly, and some have symptoms for a few weeks. Symptoms may last up to 2 weeks. If they last longer, see a doctor. Symptoms lasting beyond 10 to 14 days are also a reason to see a doctor.
• Home advice: in the first few days, put an ice pack on the spot several times for short periods, rest, take paracetamol for headache, and have an adult with you for at least the first 24 hours. Do not go to work or school until you feel well, do not drive until fully recovered, avoid contact sport for at least 3 weeks, and avoid alcohol and drugs.
• A more serious injury. Rehabilitation may be needed: physiotherapy for movement, occupational therapy for daily tasks and speech therapy for speaking and swallowing. Recovering from a haematoma can be hard physically and emotionally, and sometimes difficulty with walking, speaking and thinking, or seizures, remain.

The result depends on the severity of the injury, age and general health, and it differs for each patient. This page gives no figures or percentages, because they mean little for the person who is you or someone you love.

Risks

• A second blow. A second concussion before the first has fully healed is rare but can be dangerous, so after an injury avoid activities that could lead to another blow.
• Risks of surgery. Every brain operation has risks. The surgeon talks about them with you or your family before the operation.
• Symptoms that stay. Problems with concentration, memory, mood, tiredness or sleep may last weeks to months after a concussion. After more serious injuries, difficulty with walking, speaking or seizures may remain.

When to call

After a blow to the head, at home or after discharge, call 115 at once or go to an emergency department if:

• the headache gets worse or does not go away
• there is repeated or severe vomiting
• the person has a seizure
• the person passes out or cannot be woken
• speech becomes unclear, or there is weakness, numbness or worse balance
• any other symptom gets worse

If concussion symptoms last more than 2 weeks, or you are not sure you can drive or return to work, see a doctor.

The full list is in “When should I call urgently?” in the guide section. Every patient’s treatment plan is different; ask your doctor about your own situation.