Types of head Injury & brain trauma
A head injury can be either open or closed. An open head injury generally
involves a wound caused by a missile (ie. bullet) or some other type of open
wound. Such injuries are rare. In contrast, closed head injuries are relatively
common and occur when a child’s head strikes a hard surface, or they
experience acceleration/ deceleration forces, either with or without impact to
the skull.
Two types of injuries are generally seen with closed head injuries: focal and
diffuse. Focal injury results from impact and is associated with a skull
fracture or brain contusion (bruising). This type of injury occurs when the
child’s head impacts with an object. Damage to the brain may occur at both
the point of impact (coup) as well as the brain region where the brain
rebounds from the impact (contrecoup). The contracoup impact is opposite
the point of original impact, and may be bruised or have a hematoma
(bleeding). Thus, hitting ones head at the front may also result in damage to
the back of the brain.
Diffuse Injury is the result of the tearing of the neurons in the brain (both gray
and white matter) due to the acceleration and deceleration of the brain. This
diffuse injury is commonly seen in brain structures that are involved in the
transfer of information around the brain (corpus callosum & internal
capsule) as well as in structures involved in balance and motor movements
(cerebellum). Damage is also seen in the front of the brain in the area of the
eye sockets, which influences behaviour, emotion, memory and attention.
Your child may also have secondary effects of the head injury such as brain
swelling, areas of ischemia (death of brain neurons), contusions of the
brain, hemorrhage, and subdural hematomas.
Severity of head injury
The Glasgow Coma Scale (GCS) is usually used to determine the severity of
head injury. The higher the score the less impairment is present. The length
of posttraumatic amnesia (PTA) is the time it takes for your child to
understand time and spatial orientation and to recall prior events. The longer
the PTA and lower the GCS, the more likely your child will suffer more severe
and longer lasting cognitive problems.
Mild head injury: PTA< 1 hour, GCS 13-15
Moderate head injury: PTA 1-24 hours, GCS 9-12
Severe head injury: PTA> 24 hours, GCS 3-8
Brain structures and function
Brainstem: The brainstem is comprised of 5 areas. The medulla oblongata
is a continuation of the spinal cord and contains both sensory (ascending)
and motor (descending) nuclei. It is at the medulla where sensory and motor
tracts cross over into the opposite side of the brain so that sensory and
motor information on the right side of the body is controlled by the left side of
the brain (and vice versa). The recticular activating system (part of the
medulla) is the arousal system and controls blood pressure, blood volume
in organs, heart rate, and regulates sleep and wakefulness. This system
maintains consciousness ad attentional states for the brain and has been
hypothesised to be involved in ADHD symptoms.
Cerebellum: The cerebellum is involved in the unconscious adjustment of
muscles in the body for coordinated, smooth and complex motor activity.
Injury can result in movement disorders ( dystaxia), slurred speech
(dysarthria), blurred vision and dizziness (nystagmus), and loss of muscle
tone (hypotonia). This region is one of the most common regions for
tumours in children.
Limbic system: The limbic system is comprised of the hippocampus,
septum, and cingulate gyrus. It is involved in responses to threatening
situations, sexual responses, memory, emotion.
Basal Ganglia: The basal ganglia is comprised of the caudate nucleus,
putamen, globus pallidus and the amygdala.
Cortex: Frontal Lobes: UNDER CONSTRUCTION
Cortex: Parietal Lobes:
Cortex: Occipital Lobes:
Cortex: Temporal Lobes:
Neuropsychological problems following brain injury
The neuropsychological sequelae following a brain injury will vary according
to the age at which the TBI occurred, the time which has elapsed since the
injury, and the location, focal specificity, and extent of the lesion. Generalised
impairments in intellectual functioning are typically as a result of an injury
that is severe, diffuse, or multifocal in nature. There is a negative correlation
between the severity of the brain trauma and global IQ scores. Often
nonverbal IQ scores are lower than Verbal IQ scores. This may be due to the
nonverbal subtests loading highly upon psychomotor functioning and speed
of information processing, which are often impaired after brain trauma.
Memory, new learning, and attentional problems are the most common
cognitive sequelae of TBI in children. The more severe the injury the more
significant and persisting the memory deficits will be. Although both verbal
and nonverbal memory deficits are common, verbal memory is especially
sensitive to closed head injuries affecting the left hemisphere. Other
memory problems include deficits in encoding, and immediate and delayed
recall. Attention and concentration difficulties may also be observed,
including problems with sustained, selective, and divided attention. In
general, the greatest risk for attention and concentration problems occurs in
the initial posttraumatic period for all degrees of severity, but then the risk
shifts disproportionally toward the severely injured at short-term and long-
term follow-up.
After TBI children may also exhibit difficulties with executive abilities. They
may show deficits in problem solving, planning, organization, mental
flexibility, fluency, inhibition and behavioural regulation. Other deficits include
slowed speed of information processing, which is inversely proportional to
the severity of TBI. Language deficits may also be observed, although
classic aphasia syndromes are infrequent in children. They may have
problems with fluency, repetition, and written language. Head injured
children often perform more poorly on motor tasks, such as finger tapping
and motor dexterity, even in the absence of more gross motor impairments.
Motor slowing is only likely to persist in severely injured children. Many of the
deficits associated with TBI in children can undermine academic
performance in areas such as reading writing, and mathematics. Children
may also exhibit headaches, fatigue, irritability, lethargy, sleep disruptions,
and possibly behavioural and personality changes after sustaining a TBI.
Although many of the deficits seen in children who sustain a TBI are similar
to those seen in adults there are some important differences.
Neuropsychological sequelae may differ between children and adults as the
causes of TBI in children are more variable than in adults and their
pathophysiological responses to injury differ. Evidence suggests that
children have an increased probability of survival and better motor-sensory
recovery. It has been postulated that recovery may be greater in children than
in adults due to the plasticity of children’s brains and possible
reorganization of function. However, some studies have found that children
who sustained a head injury prior to seven years of age performed more
poorly than those who were injured after 7.
The neuropsychological sequelae of TBI in children is much more complex
and variable than in adults as children have to both regain the abilities they
have lost as well as continue to acquire new skills. Therefore deficits may
accumulate with time or possibly only appear after a certain period following
the injury. Maturational, psychosocial, and cognitive factors interact more in
children than in adults, and children are more emotionally vulnerable to the
impact of their injuries on the family and on their social relationships.
Treatment of cognitive problems following brain injury
At the Sydney Cognitive development Centre we assess and treat the
cognitive, behavioural, social, academic and emotional problems that arise
following a TBI. We also offer parent and family support and counselling
through the difficult recover phase.
For an appointment please call (02) 9387 6166.
A head injury can be either open or closed. An open head injury generally
involves a wound caused by a missile (ie. bullet) or some other type of open
wound. Such injuries are rare. In contrast, closed head injuries are relatively
common and occur when a child’s head strikes a hard surface, or they
experience acceleration/ deceleration forces, either with or without impact to
the skull.
Two types of injuries are generally seen with closed head injuries: focal and
diffuse. Focal injury results from impact and is associated with a skull
fracture or brain contusion (bruising). This type of injury occurs when the
child’s head impacts with an object. Damage to the brain may occur at both
the point of impact (coup) as well as the brain region where the brain
rebounds from the impact (contrecoup). The contracoup impact is opposite
the point of original impact, and may be bruised or have a hematoma
(bleeding). Thus, hitting ones head at the front may also result in damage to
the back of the brain.
Diffuse Injury is the result of the tearing of the neurons in the brain (both gray
and white matter) due to the acceleration and deceleration of the brain. This
diffuse injury is commonly seen in brain structures that are involved in the
transfer of information around the brain (corpus callosum & internal
capsule) as well as in structures involved in balance and motor movements
(cerebellum). Damage is also seen in the front of the brain in the area of the
eye sockets, which influences behaviour, emotion, memory and attention.
Your child may also have secondary effects of the head injury such as brain
swelling, areas of ischemia (death of brain neurons), contusions of the
brain, hemorrhage, and subdural hematomas.
Severity of head injury
The Glasgow Coma Scale (GCS) is usually used to determine the severity of
head injury. The higher the score the less impairment is present. The length
of posttraumatic amnesia (PTA) is the time it takes for your child to
understand time and spatial orientation and to recall prior events. The longer
the PTA and lower the GCS, the more likely your child will suffer more severe
and longer lasting cognitive problems.
Mild head injury: PTA< 1 hour, GCS 13-15
Moderate head injury: PTA 1-24 hours, GCS 9-12
Severe head injury: PTA> 24 hours, GCS 3-8
Brain structures and function
Brainstem: The brainstem is comprised of 5 areas. The medulla oblongata
is a continuation of the spinal cord and contains both sensory (ascending)
and motor (descending) nuclei. It is at the medulla where sensory and motor
tracts cross over into the opposite side of the brain so that sensory and
motor information on the right side of the body is controlled by the left side of
the brain (and vice versa). The recticular activating system (part of the
medulla) is the arousal system and controls blood pressure, blood volume
in organs, heart rate, and regulates sleep and wakefulness. This system
maintains consciousness ad attentional states for the brain and has been
hypothesised to be involved in ADHD symptoms.
Cerebellum: The cerebellum is involved in the unconscious adjustment of
muscles in the body for coordinated, smooth and complex motor activity.
Injury can result in movement disorders ( dystaxia), slurred speech
(dysarthria), blurred vision and dizziness (nystagmus), and loss of muscle
tone (hypotonia). This region is one of the most common regions for
tumours in children.
Limbic system: The limbic system is comprised of the hippocampus,
septum, and cingulate gyrus. It is involved in responses to threatening
situations, sexual responses, memory, emotion.
Basal Ganglia: The basal ganglia is comprised of the caudate nucleus,
putamen, globus pallidus and the amygdala.
Cortex: Frontal Lobes: UNDER CONSTRUCTION
Cortex: Parietal Lobes:
Cortex: Occipital Lobes:
Cortex: Temporal Lobes:
Neuropsychological problems following brain injury
The neuropsychological sequelae following a brain injury will vary according
to the age at which the TBI occurred, the time which has elapsed since the
injury, and the location, focal specificity, and extent of the lesion. Generalised
impairments in intellectual functioning are typically as a result of an injury
that is severe, diffuse, or multifocal in nature. There is a negative correlation
between the severity of the brain trauma and global IQ scores. Often
nonverbal IQ scores are lower than Verbal IQ scores. This may be due to the
nonverbal subtests loading highly upon psychomotor functioning and speed
of information processing, which are often impaired after brain trauma.
Memory, new learning, and attentional problems are the most common
cognitive sequelae of TBI in children. The more severe the injury the more
significant and persisting the memory deficits will be. Although both verbal
and nonverbal memory deficits are common, verbal memory is especially
sensitive to closed head injuries affecting the left hemisphere. Other
memory problems include deficits in encoding, and immediate and delayed
recall. Attention and concentration difficulties may also be observed,
including problems with sustained, selective, and divided attention. In
general, the greatest risk for attention and concentration problems occurs in
the initial posttraumatic period for all degrees of severity, but then the risk
shifts disproportionally toward the severely injured at short-term and long-
term follow-up.
After TBI children may also exhibit difficulties with executive abilities. They
may show deficits in problem solving, planning, organization, mental
flexibility, fluency, inhibition and behavioural regulation. Other deficits include
slowed speed of information processing, which is inversely proportional to
the severity of TBI. Language deficits may also be observed, although
classic aphasia syndromes are infrequent in children. They may have
problems with fluency, repetition, and written language. Head injured
children often perform more poorly on motor tasks, such as finger tapping
and motor dexterity, even in the absence of more gross motor impairments.
Motor slowing is only likely to persist in severely injured children. Many of the
deficits associated with TBI in children can undermine academic
performance in areas such as reading writing, and mathematics. Children
may also exhibit headaches, fatigue, irritability, lethargy, sleep disruptions,
and possibly behavioural and personality changes after sustaining a TBI.
Although many of the deficits seen in children who sustain a TBI are similar
to those seen in adults there are some important differences.
Neuropsychological sequelae may differ between children and adults as the
causes of TBI in children are more variable than in adults and their
pathophysiological responses to injury differ. Evidence suggests that
children have an increased probability of survival and better motor-sensory
recovery. It has been postulated that recovery may be greater in children than
in adults due to the plasticity of children’s brains and possible
reorganization of function. However, some studies have found that children
who sustained a head injury prior to seven years of age performed more
poorly than those who were injured after 7.
The neuropsychological sequelae of TBI in children is much more complex
and variable than in adults as children have to both regain the abilities they
have lost as well as continue to acquire new skills. Therefore deficits may
accumulate with time or possibly only appear after a certain period following
the injury. Maturational, psychosocial, and cognitive factors interact more in
children than in adults, and children are more emotionally vulnerable to the
impact of their injuries on the family and on their social relationships.
Treatment of cognitive problems following brain injury
At the Sydney Cognitive development Centre we assess and treat the
cognitive, behavioural, social, academic and emotional problems that arise
following a TBI. We also offer parent and family support and counselling
through the difficult recover phase.
For an appointment please call (02) 9387 6166.
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| Traumatic Brain Injury |
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| Sydney Cognitive Development Centre |
Maximising your child's potential
| Sydney Cognitive Development Centre |