Cerebral Contusion (Brain Bruise)

What happens in a brain contusion

The brain floats in fluid inside the skull. A blow or sudden acceleration and deceleration makes the brain strike the inside of the skull. The rough bony ridges at the base of the skull damage the undersides of the frontal and temporal lobes in particular. Small blood vessels tear, causing bleeding within the brain tissue, surrounded by swelling (edema).

• Coup injury: at the site of impact.
• Contrecoup injury: on the opposite side, as the brain rebounds. A fall onto the back of the head often causes frontal contusions.

Contusions are different from:

• Concussion: a functional brain injury without visible bleeding on a scan.
• Hematomas: collections of blood outside the brain, such as a subdural or epidural hematoma.
• Diffuse axonal injury: widespread shearing of nerve fibers.

These injuries frequently occur together.

Symptoms

• headache, which may worsen
• confusion, disorientation or drowsiness
• loss of consciousness at the time of injury (not always)
• memory loss around the event
• nausea and vomiting
• weakness or numbness on one side
• speech or language difficulty
• vision changes
• seizures
• irritability, agitation or personality change, especially with frontal lobe contusions

Why contusions can get worse

Contusions often "blossom": they enlarge or new ones appear in the first 24 to 72 hours as bleeding continues and swelling develops. Swelling peaks around days 3 to 5. Rising pressure inside the skull can cause worsening headache, drowsiness, vomiting and, in severe cases, brain herniation. This is why patients are monitored closely and scanned again.

Risk of enlargement is higher in older adults, people on anticoagulant or antiplatelet medicines, people with low platelets or clotting problems, and with larger initial contusions.

Diagnosis

• Glasgow Coma Scale (GCS): scores eye opening, speech and movement to grade severity.
• Neurological examination: pupils, strength, sensation, speech.
• CT scan of the head: the first-line test, showing contusions as bright spots of bleeding with dark surrounding swelling. A repeat CT is often done within 6 to 24 hours or if symptoms change.
• MRI: shows smaller contusions and associated axonal injury more clearly, usually later.
• Blood tests: clotting, platelets, sodium.

Treatment

Hospital observation

• frequent neurological checks
• head of bed raised about 30 degrees
• avoiding low oxygen, low blood pressure and fever, which worsen brain injury
• correcting clotting problems and reversing anticoagulants
• controlling blood sugar and sodium

Medicines

• Antiseizure medicine for a week after moderate to severe injury reduces early seizures
• Pain relief, avoiding NSAIDs early because of bleeding risk
• Hyperosmolar therapy (mannitol or hypertonic saline) to reduce brain swelling

Intensive care

People with severe injuries may need intracranial pressure monitoring, a breathing tube and sedation.

Surgery

Surgery is considered for large contusions causing mass effect, rising pressure or neurological decline, especially in the temporal lobe. Options include removing the contusion (evacuation) or removing part of the skull (decompressive craniectomy) to allow swelling.

Recovery

Recovery depends on the size and location of the contusion, other brain injuries and age.

• Small contusions often heal over weeks, with headaches, fatigue and concentration problems settling over months.
• Frontal contusions can affect planning, judgment, behavior and emotional control.
• Temporal contusions can affect memory and language.
• About 1 in 10 people with significant contusions develop later seizures.

Rehabilitation with physical, occupational and speech therapy, neuropsychology and gradual return to work or school is central. Avoid alcohol, which slows recovery and raises seizure risk, and do not drive until cleared. Protect against a second head injury while healing.

Prevention

• seat belts and child car seats
• helmets for cycling, motorcycling, skiing and contact sports
• fall prevention for older adults: exercise, home safety, vision checks, medicine review
• avoiding alcohol when driving or at heights

Frequently asked questions

What is a cerebral contusion?

A cerebral contusion is a bruise of the brain tissue caused by a head injury. Small blood vessels bleed into the brain, and the area swells. It is a type of traumatic brain injury seen on a CT scan, and it can worsen over the first few days.

What are the symptoms of a brain bruise?

Symptoms include headache, confusion, drowsiness, nausea and vomiting, memory loss, weakness or numbness, speech problems, seizures and personality changes. Symptoms depend on the size and location of the bruise. Any of these after a head injury needs emergency assessment.

How long does it take to recover from a cerebral contusion?

Small contusions may heal within weeks, though headaches, tiredness and concentration problems can persist for months. Larger contusions may take many months of rehabilitation, and some people have lasting difficulties with memory, behavior or movement.

What is a coup-contrecoup injury?

It describes brain bruising at the point of impact (coup) and on the opposite side (contrecoup), as the brain rebounds inside the skull. For example, falling backward and hitting the back of the head often bruises the front of the brain.

Is a brain contusion serious?

It can be. Small contusions often heal well, but contusions can enlarge in the first few days and raise pressure inside the skull. That is why people are kept in hospital for monitoring and repeat scans. Larger contusions may need surgery.