1. The following lecture has been approved for
University Undergraduate Students
This lecture may contain information, ideas, concepts and discursive anecdotes
that may be thought provoking and challenging
It is not intended for the content or delivery to cause offence
Any issues raised in the lecture may require the viewer to engage in further
thought, insight, reflection or critical evaluation

2. craig.jackson@uce.ac.uk
Introduction to
Brain Injury
Dr. Craig Jackson
Senior Lecturer in Health Psychology
School of Health and Policy Studies
Faculty of Health & Community Care
University of Central England

3. What was Michael Angelo’s Hidden Message?
Michelangelo. The Creation of Adam (detail, Sistine Chapel).
1510. Fresco. Sistine Chapel, Vatican, Rome.

4. Objectives
List major structures and function of nervous system
Name types of head and spine injuries; describe clinical features
Describe mechanisms of neurological
injury
Describe assessment of head injuries
Describe functional affects and symptoms
Describe imaging techniques

5. Neurological Injuries
Responsible for 50+% of trauma deaths
Approx. 1,000,000 patients in UK attend A&E with head injury per year
Can be prevented (some extent) by helmets and PPE
Major cause of chronic disability
Mostly from Falls, RTAs and Assaults
Flannery & Buxton, 2001

6. Anatomy Principles
Neuron
specialized nerve cell
Dendrites and Axons
short and long processes of neurons
Peripheral neurons sheathed with myelin
Impulses transmitted from synapses to dendrites

7. Anatomy Principles 2
Central Nervous System = brain, spinal cord
Peripheral Nervous System = nerves, branches
Meninges = protective triple layer cover
Dura matter = outer layer
Arachnoid = middle layer
Pia matter = inner layer
Cerebral Spinal Fuid (CSF) circulates in middle layer

8. Anatomy Principles 3
Cerebrum (hemispheres)
Cerebellum, brainstem
Cranial nerves
originate at base of brain
Sensory / motor supply to head and face
Motor nerves = brain to muscle units
Sensory nerves = skin back to brain
Somatic Nervous System = voluntary action
Automatic Nervous System = involuntary action

9. Anatomy Principles 4

10. Traumatic Brain Injury
Physical force causes nerve cells to stretch, tear and pull apart
Unable to relay messages through brain
Force causes brain to slam against skull interior: “Traumatic Brain Injury”
Injury to brain cells affects processing:
thinking
remembering
seeing
control & coordination
mood

11. Traumatic Brain Injury
TBI ranges from mild to severe:
degree of force
multiple trauma
neurological complications
speed of assistance

12. Head Injuries
Severity depends on amount of Primary and Secondary brain injury
Main cause of Secondary injury = hypoxia
Categories: Open or Closed
Forces: Shearing and Compression

13. Non Loss of Function
41 yr old Mike Hill
Attacked from behind
Full recovery after removal
No infection
Left hospital 1 week after removal
Epileptic medication and some memory problems

14. Functional Status
SPECT image with Technetium (T99)

15. Pathophysiological Disturbance
Involve scalp, cranium, or underlying brain
Depends on mechanism of injury
Scalp: lacerations, contusions, abrasions
Skull fractures: vault / base, simple or compound, depressed or planar
Primary Brain Injury: Focal (intra-cranial haematoma, contusion)
Diffuse (diffuse axonal injury)
Categories: Open or Closed
Forces: Shearing and Compression

16. “Closed” or “Open” Head Injury
Closed Head Injury (CHI): No penetration of the skull
Usually a TBI
Not always though
Open head Injury (OHI): Bullet, Knife, or Fracture
Skull breeched
Brain injury depends on power of physical force injury
If great enough, forces radiates through skull, causes sudden brain movement
Results in damaged nerve cells
May result in “soft tissue” injury - cervical strain
myofascial trauma

17. “Mild” Traumatic Brain Injury
Head injury graded on: (i) length of unconsciousness
(ii) length of amnesia
Both caused by sudden trauma and nerve cell tearing
Brain cannot maintain functioning and shuts down either:
fully (unconsciousness) or partially (dazed)
MBI refers to loss of consciousness for 30 mins or less
Unconscious
Amnesia Any of these Diffuse Axonal
Altered consciousness indicates MBI Injury
neurological deficits
MBI can result in life changing consequences

18. Diffuse Axonal Injury
Thinking slows down
Memory poor Mild Brain Injury Processing slower
Concentration haphazard
“Roadblocks of damaged unconnected neurons”
Individual feels:
Incomplete emotional problems
Unconfident
Frustrated Described as “ mental fog”
Irritable
Struggling cognitive problems

19. Brain Injury without Direct Trauma
Whiplash & Shaking
Sudden movement inside cranium damages neurons
Acceleration – Deceleration
RTAs – even with airbag deployment –can cause brain injury
Brain is torn, squashed, bruised
Rollercoasters

20. Types of Head Injuries
Concussion: Temporary alteration in neurological function or LOR
Cerebral Contusion: Bruised brain
Cerebral Haemotoma or bleed
epidural
sub-dural
sub-arachnoid
intra-cerebral

21. Signs and Symptoms
Headache
Dizziness
Nausea / Vomiting
Amnesia
Decreased responsiveness
Confusion
Combativeness
Loss of responsiveness

22. Assessment
First impression: Responsive or Unresponsive
Urgent Survey: LOR ABC’s
Open airway with C-spine
Check breathing: Ventilate; Oral airway; O2 when available
Check carotid artery pulse – CPR if indicated
Control any major bleeding

23. Assessment continued
Rapid Body Survey Sample, DCAP-BTLS
Stabilize head between knees
Call for equipment, assistance, transport
Maintain body temp.
Transport (head uphill)
Non-Urgent Survey
Ongoing Survey – seizures, vomiting, change in LOR

24. Assessment continued
Brain Swelling

Increased Intracranial Pressure (ICP)

Hypoxia

Further Secondary Brain Injury

More Swelling

Increased ICP

25. Localised Neurological Signs (ICP)
GENERAL SIGNS + PLUS +
Change in pupil size / light reactivity
Slowing pulse
Rising BP.
Change in respiration
Unilateral weakness
Incontinence
Seizure

26. Urgent Interventions - ATLS
Presume C-Spine injury
Immobilize neck
Open airway: administer oxygen
Treat bleeding and shock
Prevent aspiration of vomit / secretions
Transport immediately
Elevate head 6”
Transport head uphill

27. Imaging
Xray, MRI and CT cannot show traumatic
brain injury
Techniques rely on tissue density
Diffuse damage will not show on these
techniques
SPECT or PET measure brain cell metabolism
Can detect changes in function due brain injury

28. Behavioural Changes
Speech
Cognition
Memory
Mood
Mental health
psychoses
delirium
Tremor
Gait
Symmetry of function Gross over-simplification
Visual
Auditory
Positive and negative symptoms

29. Other Causes of Brain Injury
Drug effects
Tumor
Metastases
Physical assault
Surgery
Traumatic birth
Hypoxia

30. Glasgow Coma Scale
Scores 8 or less = needs urgent anaesthetic assessment.
Danger of airway compromise
13-15 = mild 9-12 = moderate 3-8 = severe

31. Queen’s Medical Centre

32. Cerebral Asymmetry of Function
Hemispheric asymmetry of function is relative
Asymmetries have been overblown by popular media into fads
(e.g. golf with your right brain)
Anterior-posterior differences far outweigh left-right differences
Asymmetry is not uniquely human

33. Cerebral Asymmetry of Function
LEFT HEMISPHERE
Convolutions mature more rapidly
Extends further posteriorly
Higher in density (more gray matter; more neurons)
Planum temporale larger on left (in 60-90%) of cases
Larger insula
Longer Sylvian fissure (gentler slope)
Double cingulate gyrus
Larger lateral posterior nucleus (to parietal cortex)
Wider occipital lobe
Larger total area of frontal operculum (much buried in sulci)
Larger inferior parietal lobule

34. Cerebral Asymmetry of Function
RIGHT HEMISPHERE
Convolutions mature less rapidly
Extends further anteriorly
Larger and heavier
Primary auditory (Heshl's gyrus) larger on right
Shorter (steeper slope)
Single
Larger medial geniculate nucleus
Narrower
Larger area of convexity in frontal lobe; wider frontal lobe

35. Cortical Lesions
Human cognitive and sensory dysfunction different following lesions
(due to strokes, surgery, accident, etc.)
Differences noted in lesions to left and right hemispheres
Lesions can provide clues about brain organization
Do specific areas possess special unique functions?
Does a lesion to a specific area demonstrate a dysfunction
+
Lesions to other brain locations do not cause a similar dysfunction

36. Dissociation
Lesion site Reading Writing Speaking
100 normal normal impaired
102 impaired normal normal
104 normal impaired normal
Allows understanding of specific sites and impairments

37. Hemispherical Function
Left Right
Vision linguistic stimuli patterns faces
steropsis
Audition language sounds
rhythm
Somatosensation tactile recognition
Motor complex movement spatial movement
Memory verbal memory non-verbal memory
Language speech reading prosody
writing arithmetic
Emotion social emotions primary emotions
Spatial processes geometry spatial images orientation

38. Split Brain and Commissurotomy
Corpus Callosum joins hemispheres
Sever corpus callosum
Two hemispheres cannot communicate

39. Brain Injury - Summary
1. The main cause of secondary damage to the brain is _ _ _ _ _ _ _ ?
2. Head injury alone rarely causes damage. T / F?
3. Temporary loss of consciousness or function from a head trauma is a
__________?
4. Brain injury can occur without any impact trauma. T / F
5. Axons being damaged / shredded is the simple reason for cognitive
problems in head injury patients. T / F

40. Hemispherical test
I always wear a watch
1

41. Hemispherical test
I keep a journal
2

42. Hemispherical test
I believe there is a right and wrong way to do everything
3

43. Hemispherical test
I hate following directions
4

44. Hemispherical test
The expression "Life is just a bowl of cherries" makes no
sense to me
5

45. Hemispherical test
I find that sticking to a schedule is boring
6

46. Hemispherical test
I'd rather draw someone a map the tell them how to get
somewhere
7

47. Hemispherical test
If I lost something, I'd try to remember where I saw last
8

48. Hemispherical test
If I don't know which way to turn, I let my emotions guide me
9

49. Hemispherical test
I'm pretty good at math
10

50. Hemispherical test
If I had to assemble something, I'd read the directions first
11

51. Hemispherical test
I'm always late getting places
12

52. Hemispherical test
Some people think I'm psychic
13

53. Hemispherical test
Setting goals for myself helps keep me from slacking off
14

54. Hemispherical test
When somebody asks me a question, I turn my head to the
left
15

55. Hemispherical test
If I have a tough decision to make, I write down the pros and
the cons
16

56. Hemispherical test
I'd make a good detective
17

57. Hemispherical test
I am musically inclined
18

58. Hemispherical test
If I have a problem, I try to work it out by relating it to one I've
had in the past
19

59. Hemispherical test
When I talk, I gesture a lot
20

60. Hemispherical test
If someone asks me a question, I turn my head to the right
21

61. Hemispherical test
I believe there are two sides to every story
22

62. Hemispherical test
I can tell if someone is guilty just by looking at them
23

63. Hemispherical test
I keep a to do list
24

64. Hemispherical test
I feel comfortable expressing myself with words
25

65. Hemispherical test
Before I take a stand on an issue, I get all the facts
26

66. Hemispherical test
I've considered becoming a poet, a politician, an architect, or
a dancer
27

67. Hemispherical test
I lose track of time easily
28

68. Hemispherical test
If I forgot someone's name, I'd go through the alphabet until I
remembered it
29

69. Hemispherical test
I like to draw
30

70. Hemispherical test
When I'm confused, I usually go with my gut instinct
31

71. Hemispherical test
I have considered becoming a lawyer, journalist, or doctor
32

72. Hemispherical test
1. L
2. L
3. L
4. R
5. L
6. R
7. R
8. L
9. R
10. L
11. L
12. R

73. Hemispherical test
13. R
14. L
15. R
16. L
17. L
18. R
19. R
20. R
21. L
22. R
23. R
24. L

74. Hemispherical test
25. L
26. L
27. R
28. R
29. L
30. R
31. R
32. L