What Happens Immediately After the Injury?

Icahn School of Medicine at Mount Sinai
What Happens Immediately After the Injury?

What happens to the brain at the point of injury?

Traumatic brain injury (TBI) refers to damage or destruction of brain tissue due to a blow to the head, resulting from an assault, a car crash, a gunshot wound, a fall, or the like.

In closed head injury, damage occurs because the person receives a blow to the head that whips the head forward and back or from side to side (as in a car crash), causing the brain to collide at high velocity with the bony skull in which it is housed. This jarring bruises brain tissue and tears blood vessels, particularly where the inside surface of the skull is rough and uneven; damage occurs at (and sometimes opposite) the point of impact. Thus, specific areas of the brain - most often the frontal and temporal lobes - are damaged. This focal damage often can be detected through MRI and CAT scans.

In closed head injury, the rapid movement of the brain can also stretch and injure neuronal axons - the long threadlike arms of nerve cells in the brain that link cells to one another, that link various parts of the brain to each other and that link the brain to the rest of the body. This widespread axonal injury interrupts functional communication within and between various brain regions and sometimes between the brain and other body parts. However, this type of diffuse damage typically cannot be detected through currently available imaging technology (but with new developments, this may change). Its existence is very clear, however, in the widespread effects it has on the individual's functioning.

In sum, after a closed head injury, damage can occur both in specific brain areas (due to bruising and bleeding) and also be found throughout the brain (due to stretched or destroyed axons). The results of a closed head injury tend to affect broad areas of the individual's functioning, primarily due to the diffuse axonal injury. The extent of damage is correlated with the force of the blow to the head; for example, a head forced into a car windshield at high speed will tend to sustain more tissue damage than when the car is traveling at a slower speed.

Open head injury, the second type of TBI, occurs when the skull is penetrated, for example by a bullet. Damage following open head injuries tends to be focal, not diffuse, and the implications for subsequent impairment tend, also, to be focal and limited. However, such injuries can be as severe as closed head injuries, depending on the destructive path of the bullet or other invasive object within the brain.

What happens immediately after TBI?

Immediately following TBI, two types of effects are seen. First, brain tissue reacts to trauma and to tissue damage with a series of biochemical and other physiological responses. Substances that once were safely housed within the cells now flood the brain. These processes further damage and destroy brain cells, in what is called secondary cell death.

The second type of effect is seen in the individual's functioning. For those with more severe injuries, loss of consciousness (LOC) occurs at the time of trauma, lasting from a few minutes or hours to several weeks or even months. Lengthy LOC is referred to as coma. In such serious injuries, the first few days after trauma may also produce negative changes in respiration (breathing) and motor functions.

As an individual regains consciousness (those with the severest injuries may never do so), a variety of neurologically based symptoms may occur: irritability, aggression and other problems. Post-traumatic amnesia (PTA) is also typically experienced when an injured person regains consciousness. PTA refers to the period when the individual feels a sense of confusion and disorientation - Where am I? What happened? - and an inability to remember recent events.

As time passes, these responses typically subside, and the brain and other body systems again approach physiological stability. But, unlike tissues such as bone or muscle, the neurons in the brain do not mend themselves. New nerves do not grow in ways that lead to full recovery. Certain areas of the brain remain damaged, and the functions that were controlled by those areas may emerge as challenges in the individual's life.

Before discussing in greater detail what happens to the person after injury, which depends to great extent on the severity of injury, "severity" needs to be defined (in the next question).

What is meant by "severity of injury?"

Typically, "severity of injury" refers to the degree of brain tissue damage. Although the degree of such damage cannot be directly measured, it is estimated typically by measuring the duration of loss of consciousness (LOC) and the depth of coma (and sometimes by the length of PTA).

The scale most commonly used to measure the depth of coma is the Glasgow Coma Scale (GCS). The GCS is used to rate three aspects of functioning: eye opening, motor response, and verbal response. Individuals in deep coma score very low on all these aspects of functioning, while those less severely injured or recovering from coma score higher.

A GCS score of 3 indicates the deepest level of coma, describing a person who is totally unresponsive. A score of 9 or more indicates that the person is no longer in coma, but is not fully alert. The highest score (15) refers to a person who is fully conscious.

Severity of injury is typically categorized into three levels: mild (or minor), moderate and severe. A commonly used rule of thumb is that mild injury refers to LOC of less than 20 minutes and an initial GCS of 13-15. Typically, an initial GCS of 9-12 defines a moderate injury and 3-8 a severe injury.

Although initial "severity" measures may generally predict long-term impairment, initial severity scores do not correlate well with negative consequences in a person's life. The effects of TBI on individuals and the meaning of those effects depend upon a wide variety of factors, only one of which is initial "severity of injury."

How long does recovery take?

Recovery after injury is usually quite different for those with moderate-to-severe injuries versus those with mild injuries. And, as must be constantly kept in mind, recovery varies greatly from person to person. Thus, recovery will not be the same for any two people with TBI.

In mild TBI, one person may recover quickly and completely, while another may experience significant challenges even several years after injury. (Recovery after mild TBI is discussed more fully in a later question, What Impact Will Mild TBI Have ona Person's Life?)

In more severe injuries, recovery is a multistage process, which typically continues in a variety of ways for months and years. However, the length of this recovery process is not uniform, and the stages of recovery that are typical when considering the population as a whole, may be very different for any specific individual. Stages may not proceed step-wise but may overlap, one stage with the next, or one or more stages may be skipped altogether. The early recovery process is discussed more fully in the next question.

How is recovery measured right after injury?

The progress seen during the immediate recovery period in individuals with severe to moderate TBI is often tracked using the Rancho Los Amigos Scale, which specifies eight levels - from the depths of coma to return to awareness and purposeful activity. These levels of recovery of functioning reflect processes within the brain, as it heals, stabilizes, and reorganizes itself to some extent.

Although the Rancho scale assumes that recovery will pass through eight stages, a small percentage of people with severe injuries remain stuck at Levels I to III for months or years. They remain in coma or in a relatively unresponsive state and fail to return to purposeful, appropriate functioning.

Rancho Los Amigos Scale

  • Level I (No Response): The individual is in deep coma and does not respond to any stimuli.
  • Level II (Generalized Response): The person sleeps most of the time, with periods of brief wakefulness. Responses and movements are largely reflexes not purposeful.
  • Level III (Localized Response): The person is alert for lengthier periods. He/she reacts inconsistently to commands, but his/her responses are related to the type of stimulus presented. For example, noises will produce a listening response.
  • Level IV (Confused and Agitated): As awareness increases, the individual's behavior reflects his/her sense of confusion and disorganization. Aggressive and/or silly behavior may be seen, with verbal abuse, agitated actions, and incoherent speech. The person's attention span is too short to allow full cooperation in treatment programs; and the person is unable to do basic tasks, such as eating, independently.
  • Level V (Confused, Inappropriate, Not Agitated): Simple commands are now followed consistently; the person's long-term memory is returning; and she/he can now carry out over-learned skills such as eating. Difficulty is evident in following complex commands, short-term memory, learning new skills, and concentrating for more than a few minutes.
  • Level VI (Confused, Appropriate): The individual begins to show goal-directed behavior, but usually still needs direction. The person is more aware of his/her deficits, family members, and so forth. He/she can carry out more tasks independently and retains relearned skills from one occasion to the next.
  • Level VII (Automatic, Appropriate): The individual performs daily routines automatically and is better able to learn new skills, although slower than before injury. The person still has poor short-term memory; judgment and problem solving are still impaired.
  • Level VIII (Purposeful, Appropriate): The person is able to function once more in the community. Impairments in cognitive, social, and emotional functioning, to a greater or lesser extent, may continue.
Posted on BrainLine July 25, 2008.

FromIcahn School of Medicine at Mount Sinai. icahn.mssm.edu

Comments (120)

Please remember, we are not able to give medical or legal advice. If you have medical concerns, please consult your doctor. All posted comments are the views and opinions of the poster only.

How do you categorize brain injury due to radiation damage that was given for a brain tumor? This happened to me and left me barely able to function and had to access many resources and therapies.

Recent studies and treatments are showing there is more neuroplasticity than this article indicates. In addition and based on my husband's personal experience and our observation of other brain injured people, hyperbaric oxygen therapy (HBOT) provides very significant healing, even 20 years after a brain injuring event (see https://www.youtube.com/watch?v=4wa5Sjm_Nyo). For our veterans, the improvement HBOT offers is sufficient that state of Oklahoma has made law stating that veterans can get HBOT and the VA has to pay for it (see http://videos.oeta.tv/video/2365281649/). HBOT can give a person a life back instead of a life sentence.

I suffered severe brain trauma as a child and at the age of 58 became to have coherent return of my memory.  This article is very helpful.  I do wonder about the Rancho Los Amigos levels because my life is marked by much overlap.  I have always felt anxiety ridden and personally depressed while at the same time working, seeking out physical health and putting myself through college at night - very appropriate but intrinsically unhealed.  I feel I lived a bifurcated life.

What is a bifurcated life? I get the overlap but that would be sort of normal wouldn't it? I dont have a dictionary at hand and from the context I'm guessing just a bit screwed up, yes? That seems sort of normal as well so.......... what are you trying to say? How did you "become to have" coherent return of your memory at 58 , long after a childhood head injury? Did you suffer another head injury?
Have you finished your studies? You say you are anxious and depressed while working and going to school at night. That seems a good reason to be anxious but depression would be a shame while working so hard to improve yourself. Did your sudden return of memory stir up a previously unmanaged bit of your life?
Now would be a good time to manage that bifurcated intrinsically unhealed bit and get on with the rest of your appropriate life.
Stay well and get happy!!!!

What is a bifurcated life? I get the overlap but that would be sort of normal wouldn't it? I dont have a dictionary at hand and from the context I'm guessing just a bit screwed up, yes? That seems sort of normal as well so.......... what are you trying to say? How did you "become to have" coherent return of your memory at 58 , long after a childhood head injury? Did you suffer another head injury?
Have you finished your studies? You say you are anxious and depressed while working and going to school at night. That seems a good reason to be anxious but depression would be a shame while working so hard to improve yourself. Did your sudden return of memory stir up a previously unmanaged bit of your life?
Now would be a good time to manage that bifurcated intrinsically unhealed bit and get on with the rest of your appropriate life.
Stay well and get happy!!!!

The future in Brain Therapy is here. GyroStim therapy at www.cbp-centers.com gives new hope for patients with brain injury. The deep brain stimulation in the next generation activates the neuroplasticity of the brain - the brain's amazing capazity to "fix" itself.
CBP-Brain Centers in Colorado is the only place in the USA which offers this groundbreaking therapy. www.cbp-centers.com

This information is great and spot on but people with a brain tumor and brain surgery experience the same but do not get the TBI diagnosis. Is this because doctors are afraid to be sued. We need better awareness and support.

Damage can be seen through Spect-Imaging!!

How marvellous to read something that explains A.B.I. my son his two years into his recovery and his still in a rehabilitation unit.but l never give up hope.and visit every day. at

lovely explanation, this has been very help full in my revision for exams thank you.

Arthur Cortis, this comment of yours got me in a way I was completely unprepared for, like the two gunshots to the back of my head only few months back! But in this case, I've been there and I've seen it all happened. Life anew. Fears and many more fears. Trying to recognize the new person while still struggling to come to terms with the death of the old guy. It's an experience better imagined. The new normal is just as strange as the old death!

The "light" is full of fright...in your journey to return to normalcy from a TBI.

The above statement is chock full of misnomers,  but it is a beginning. Your journey has been heightened with opportunities never envisioned before. You just don't realize what is in front of you, yet. In time, everything comes into focus. How long this takes is different for everyone.

To come to terms with your new situation it must be realized you have entered into a new normal. Gone is the past you. Born again, with the benefit of prior knowledge. With benefits come anchors. Life is a balance...equalibrium is sought...you understand this much better after sustaining a TBI.

Once you come to terms with your new reality, then you can begin the road to enrichment of self. It is what it is because it is...searching, searching, searching...almost a requirement before you begin anew...make peace with new you and recall the situation is Just Right!!!

Preposterous, you say...begin anew!!!

Arthur Cortis

I'm very caught on this subject and really want to figure out how to heal axons. This article has helped me a lot and I hope to be back with more news. Thank you


A  scientist

Beautiful and encouraging. I once had a mild concussion as I took a spill from a bike 1977 just after graduating college. My concearn fits more with ptsd as a result of severe psychological trauma at age 10 December 21 1965 when I found my mother unconscious (turned out she was dead - a suicide self inflicted gunshot wound). The shock and after effect traumatized me to this day Nov 19 2014. Despite college grad school and work I first saw a therapist at age 27. And now I know that trauma had a long term effect on my brain. I am now on SSDI and I feel my mind relaxing and slipping backwards. All I can do is go with the flow. I just read that healthy eating exercise brain stimulation will help me. My emotions are heightened from my childhood and I have an excellent psychiatrist. Thank you for your Godly words.

May 12th 2001 (Mother's Day) at the age of 16 I experienced a severe tbi. I wrecked a motorcycle doing (from what the police said) anywhere from 75-120mph head on into a ford f-550 service truck. I was in a severe coma for 3 1/2 weeks and literally died 4 time throughout the initial hours/days in the hospital. I was in the hospital for approximately 4 months total. Including the inpatient rehabilitation center. I had to learn EVERYTHING down to tieing my shoes but for some reason maintained a two year college level reading ability....i have a hard time remembering much of anything before that wreck happened to me and except for triggers once in awhile that bring back memories that sometimes I wonder if they are actual or fabricated by my brain. Because a lot of times my friends or family don't even remember them happening. It is now 9-22-14 and I am still here to tell you that recovery has been very long and difficult...I still struggle with anger/temper issues as well as impulsive decisions I make without thinking things all the way through before I move forward with the decision. I am a single father at the age of 28 raising a beautiful 8 year old son, I have an associates degree and am working a job that brings in close to 70,000 dollars a year. Now, with that. I am by no means trying to brag or flaunt about my success but rather provide inspiration to victims of tbi and families of tbi victims showing them that everything can work out to be ok. With my personal tbi, I had what you would call a subduralhematoma with my brain hemoraging (bleeding) inside my skull with no room to expand due to it being a closed head Injury. The doctors put a drain into my scull to relieve the preasure until swelling and bleeding subsided. I still have a large problem relatively often with my short term memory but it has improved over the years and I am still at high risk for having seizures. (Haven't had one yet) but in closing, If you are a victim of a tbi or family of a victim of a tbi (traumatic brain injury) reading this comment. DONT LOSE HOPE!!! DONT GIVE UP!!!! PERSEVERE THROUGH IT!!! It may not be the end all be all! Everything happens for a reason!!! You may never understand why so don even bother wasting your breath asking yourself that over and over and over. Just see it through. I hope everything works out for you as it has for myself.....and if you ever doubt the ability you do have to see it through to the end. Say a prayer! I will say one with you! I'm sorry you have to/are going through this. Either way you look at things...it will all work out. God bless you!

My brother is on life support with a moderate-severe tbi. It's only been 2 days. I'm searching for hope. This story is exactly what I needed to see. Thank you for sharing

Immediately after Injury I was in a hospital ,but now I'm at home continue my recovery . I still work on my memory and I don't want memory of my accident back to me. What the doctors say I had one year in  front of me. During this time I try to help my body doing YOGA exercises and continue to wait. If you have something to say or share your own experience please just write I will be very pleased to read it.

Have a good time and enjoy your life.

Reading comment from May 4th. I have had 3 bad head injuries resulting in associated nasal, hand, and multiple rib fractures. Right side, left side, back of head. Had swelling and bruising from top of visible head from top of forehead to bottom of jaw, actual lacerations thought of contusions when actually lacerations when swelling subsided. But I have never lost conscioueness and can in fact give detailed information on entire event. Therefore I feel I have been underdisgnosed and sent walking while if I had even tole doctors I was just momentarily unconscious my care would have improved. I think the Glasgow scale is wrong, archaic and intolerable to people likeyself. I think E.R.s need to be better trained in modern lab tests for injury extent and treatment. This included immediate and followup care. I like others can be very pleasant in the E.R. then do the suffering at home in order to avoid being a beligerent patient. I am a past R.N. who lived and breathed E.R. medicine and as a student was taken under mentoring by Dr. John Weigenstein, Lansing, Michigan who founded the Vollege of Emergency Physians taking it from moonlighting to a accepted field of medicine. If he saw I was worth teaching I must have some capacity for the area. In general I think E.R. physians need to have more required ongoing education and empathy. At a hospital in Lansing, Michigan, I had the shift director actually come to me and tell me the E.R. was for emergencies, not people like me. I will fight till he I repreprimded. So if you have a head injury be your own advocate, losing consciousness is NOT a sign of severity and get rid of the Glasgow scale now. July 12, 2014

I did not experience any loss of conciousness at the start of my TBI- however, I have now had it for over a year. This article seems to be mainly about what I now call 'typical head injuries', which is what also seems to happen to 95% of those with TBIs. I know that my specific case cannot be answered but I would like to put it out there that people with ongoing concussions with minor symptoms would like to be advocated for too.
Is there a Level IX: When cut & damaged lines are re-activated and firing, bringing along with it the top-awareness that sucumbed to the orginal damage about 36 hours after the initial injury? Is there a Level X: Where the lines created and developed out of necessity when the damage was done are able to recognize the newly healed pre-injury operating lines and grow new lines enableling full operating connections? What do I do if there isn't those Levels yet? P.S. I'm medically undocumented but for 1 CT. I don't have a Doctor either. ;) They looked kinda confused...