Brain Injury Definitions

Brain injury is not an event or an outcome. It is the start of a misdiagnosed, misunderstood, under-funded neurological disease. Individuals who sustain brain injuries must have timely access to expert trauma care, specialized rehabilitation, lifelong disease management and individualized services and supports in order to live healthy, independent and satisfying lives.

  • Every 23 seconds a brain injury occurs
  • The total annual cost for Traumatic Brain Injury related injuries in the US is $60 billion
  • The Federal government spends less than $3 per brain injured person on TBI research and services per year.
  • Brain injuries are more common than Breast Cancer, HIV/AIDS, Spinal cord Injuries and Multiple Sclerosis combined.

Traumatic Brain Injury (TBI)
TBI is defined as an alteration in brain function, or other evidence of brain pathology, caused by an external force.

Acquired Brain Injury
An acquired brain injury is an injury to the brain, which is not hereditary, congenital, degenerative, or induced by birth trauma. An acquired brain injury is an injury to the brain that has occurred after birth.

Types of Brain Injury

Diffuse Axonal Injury (TBI)                              Second Impact Syndrome (TBI)

Concussion (TBI)                                                  Penetrating Injury (TBI)

Contusion (TBI)                                                     Anoxic brain injury (ABI)

Coup-contre coup injury (TBI)                       Hypoxic brain injury (ABI)

Diffuse Axonal Injury

  • A Diffuse Axonal Injury can be caused by shaking or strong rotation of the head, as with Shaken Baby Syndrome, or by rotational forces, such as with a car accident.
  • Injury occurs because the unmoving brain lags behind the movement of the skull, causing brain structures to tear.
  • A person with a diffuse axonal injury could present a variety of functional impairments depending on where the shearing (tears) occurred in the brain.


  • A concussion can be caused by direct blows to the head, gunshot wounds, violent shaking of the head, or force from a whiplash type injury.
  • Both closed and open head injuries can produce a concussion. A concussion is the most common type of traumatic brain injury.
  • A concussion is caused when the brain receives trauma from an impact or a sudden momentum or movement change. The blood vessels in the brain may stretch and cranial nerves may be damaged.
  • A person may or may not experience a brief loss of consciousness (not exceeding 20 minutes). A person may remain conscious, but feel “dazed” or “punch drunk”.
  • A concussion may or may not show up on a diagnostic imaging test, such as a CAT Scan.
  • Skull fracture, brain bleeding, or swelling may or may not be present. Therefore, concussion is sometimes defined by exclusion and is considered a complex neurobehavioral syndrome.
  • It may take a few months to a few years for a concussion to heal.


  • A contusion can be the result of a direct impact to the head.
  • A contusion is a bruise (bleeding) on the brain.
  • Large contusions may need to be surgically removed.

Coup-Contrecoup Injury

  • Coup-Contrecoup Injury describes contusions that are both at the site of the impact and on the complete opposite side of the brain.
  • This occurs when the force impacting the head is not only great enough to cause a contusion at the site of impact, but also is able to move the brain and cause it to slam into the opposite side of the skull, which causes the additional contusion.

Second Impact Syndrome “Recurrent Traumatic Brain Injury”

  • Second Impact Syndrome, also termed “recurrent traumatic brain injury,” can occur when a person sustains a second traumatic brain injury before the symptoms of the first traumatic brain injury have healed. The second injury may occur from days to weeks following the first. Loss of consciousness is not required. The second impact is more likely to cause brain swelling and widespread damage.
  • Because death can occur rapidly, emergency medical treatment is needed as soon as possible.
  • The long-term effects of recurrent brain injury can be muscle spasms, increased muscle tone, rapidly changing emotions, hallucinations, and difficulty thinking and learning.

Penetrating Injury

  • Penetrating injury to the brain occurs from the impact of a bullet, knife or other sharp object that forces hair, skin, bone and fragments from the object into the brain.
  • Objects traveling at a low rate of speed through the skull and brain can ricochet within the skull, which widens the area of damage.
  • A “through-and-through” injury occurs if an object enters the skull, goes through the brain, and exits the skull. Through-and-through traumatic brain injuries include the effects of penetration injuries, plus additional shearing, stretching and rupture of brain tissue.
  • The devastating traumatic brain injuries caused by bullet wounds result in a 91% firearm-related death rate overall.
  • Firearms are the single largest cause of death from traumatic brain injury.

Anoxic Brain Injury

Anoxic Brain Injury occurs when the brain does not receive oxygen. Cells in the brain need oxygen to survive and function. Types of Anoxic Brain Injury:

Hypoxic Brain Injury

Hypoxic Brain Injury results when the brain receives some, but not enough, oxygen.

Closed Head Injury
When a person receives an impact to the head from an outside force, but the skull does not fracture or displace this condition is termed a “closed head injury”.  With a closed head injury, when the brain swells, the brain has no place to expand. This can cause an increase in intracranial pressure, which is the pressure within the skull.


According to the Centers for Disease and Control Injury Prevention Center, the leading causes of traumatic brain injury are:

Outcomes After Brain Injury

Brain injury can result in a range of outcomes:

  • 52,000 die;
  • 275,000 are hospitalized; and
  • 1,365,000 are treated and released from an emergency department.

Among children ages 0 to 14 years, TBI results in an estimated

  • 2,685 deaths;
  • 37,000 hospitalizations; and
  • 435,000 emergency department visits.

The number of people with TBI who are not seen in an emergency department or who receive no care is unknown.

Source: Centers for Disease Control and Injury Prevention

What it is like to have a brain injury

Brain injury changes who you are. You may feel literally like a different person. Your residual effects, or deficits, are permanent. As you can imagine, this affects your relationships with a spouse, family members, co-workers, friends, even strangers – they will all have to adapt and adjust to differences in your abilities and personality.

Most survivors do not, cannot fully return to their former lives. They can’t just

“pick up where they left off” in life. They must learn to accept that their old self is gone and they are a “new” person after a brain injury.

This doesn’t mean they are stupid. A survivor may have trouble thinking or reasoning, but they are no less intelligent. What it does mean is:

A survivor’s brain has to work harder and needs more time to

process, retrieve, remember or produce information.

Interaction with individuals with brain injury

Many well-intentioned people have uncomfortable attitudes about individuals with disabilities, viewing them as persons to be pitied or ignored.  Likewise, people often think that all disabilities are visible, such as a person who uses a wheelchair, crutches or walkers.

Brain Injury is often referred to as “the unseen injury” because some people appear “fine” physically, but may still have cognitive or behavioral impairments.  Other individuals may have noticeable physical impairment.    The effects of brain injury can be categorized into three general areas:


  • Spasticity (jerky movements, stiffness or                   – Slow or slurred speech

limbs frozen in one position)                                             – Difficulty forming or finding words (aphasia)

  • Awkward movement                                                             – Flat affect (no emotions shoring on fact or in voice)

  • Muscle weakness                                                                     – Seizures

  • Paralysis                                                                                     – Deaf or hard of hearing

  • Unsteady gain and/or poor balance                               – Fatigue

  • Inability to walk a straight line                                         – Pain

  • Use of adaptive devises                                                        – Altered eye movement – cannot track object without moving their head

  • Poor hand/eye coordination

  • Staring or poor eye contact

  • Blurred or double vision

  • Sensitivity to light



  • Difficulty maintaining topic of conversation               – Difficulty listening

  • Vague, unclear language                                                      – Difficulty following directions

  • Difficulty with planning and prioritizing                        – Unable to multi-task

  • Frustration when trying to communicate                     – Not aware of personal deficits and limitations

  • Perseveration (talking about the same thing               – Poor self-esteem

over and over)                                                                           – Body language may not match verbalization

  • Inappropriate comments/responses                              – Disorientation

  • Stands too close to other people (no sense                   – Confabulation (making up stories because unable

of personal space)                                                                        to remember – this is NOT intentional lying)

  • Confusion                                                                                     – Easily distracted

  • Taking things very literally                                                   – Laughs or cries inappropriately

  • Poor short-term memory                                                      – Aggression

  • Talks too fast or too loud                                                       – Anxiety/Fear

  • May not be able to answer simple questions                 – Poor information retention

  • Lack of response OR over-responding                             – Answers or reacts slowly to situations



  • Irritability                                                                              – Lack of self-control

  • Anxiety                                                                                    – Frustration

  • Depression                                                                              – Confusion

  • Fatigue/Lethargy                                                                 – Personality changes

  • Impulsivity                                                                            – Poor initiation (trouble getting started)

  • Disinhibit ion                                                                         – Appears disinterested

  • Agitation                                                                                 – Poor social skills (responds inappropriately

  • Difficulty concentrating                                                          unable to take social sues from others)

  • Makes inappropriate and potentially                          – Inappropriate sexual advances or conversation

Harmful decisions                                                                – Visual or auditory hallucinations

  • Temper outbursts

  • Emotionally overactive/excitable

  • Verbally/physically combative

  • Paranoid or suspicious


Some DOs and DON’Ts

People with brain injury are just like us non-survivors.  They want to be treated with kindness, patience, respect, dignity, understanding and support.

Please don’t be condescending, patronizing, or treat them like children.


Identifying a Survivor

ASK.  ASK if they have ID jewelry or and ID card


If someone identifies herself as a survivor, ask her to explain her residual effects and any accommodations you can provide.

If someone seems to exhibit signs of deficits typical of brain injury, ask him if he was in the service or an accident and might have incurred a brain injury.

Know that not all survivors will admit to having a brain injury, and not all survivors may realize they have a brain injury.

Some survivors are unaware of some of their deficits (such as mood swings or anger issues).

Accommodations to Use When Talking with a Brain Injury Survivor

Reduce distractions such as lights and noise level.


Underwhelm – simplify the content of your speech. Less is more.


Speak slowly and pause often, to give the brain time to absorb and understand.


Ask one question at a time and repeat the question if necessary.


Give the person time to respond.


Avoid conversations where more than one person talks at the same time (“crosstalk”). Multi-tasking is difficult, and brains will absorb little to none of the conversation.


People with brain injury often have trouble organizing their thoughts or generating their own ideas. For this reason, don’t ask open-ended questions.

Instead:    Ask yes or no questions.

Bad question: “How are you?”

Good question: “Do you feel good or bad today?”


Check for comprehension, that the two of you are “on the same page.” Survivors can be very good “actors” to protect their pride or ego – they don’t want to admit that they aren’t following, so they’ll pretend they’ve got it when they don’t.


Ask him to “mirror” facts, decisions, directions, and plans – to repeat them back to you.


If she doesn’t “get it,” explain it more slowly or a different way, till you know she understands.