Topic Progress:

The presenting signs and symptoms of a patient with a TBI will vary depending upon the type of lesion involved and many of the symptoms can be quite non-specific.  

Often, a patient with a severe TBI may present with a loss of consciousness or be combative.  

Below are the different intracranial lesions and some of the possible signs and symptoms.

Timing:   usually develop within minutes to hours post-injury.

  • Increasing headache
  • Decreased level of consciousness
  • Focal neurologic deficits (eg, hemiparesis)
  • Non-reactive pupil dilation usually indicates herniation.
  • Some patients who have an epidural haematoma lose consciousness, then have a transient lucid interval, and then gradual neurologic deterioration.

Timing: immediate

  • Progressive decrease in consciousness
  • Focal neurological deficits.

Intracerebral Haematomas and Subdural Haematomas can cause focal neurological deficits such as hemiparesis, progressive decrease in consciousness, or both.

Progressive decrease in consciousness may result from anything that increases ICP  eg.   oedema, any intracranial lesion.


Timing:   can be delayed as oedema worsens or haemorrhage expands

Markedly increased ICP classically manifests as the Cushing triad:

  • Hypertension 
  • Bradycardia
  • Respiratory depression – breathing is often irregular and slow.


  • Decorticate or decerebrate posturing (both are poor prognostic indicators)
  • Decreased level of consciousness.

  • Unconscious Dilated and unreactive pupils, either unilateral or bilateral
  • Hemiplegia – normally contralateral to the dilated pupil
  • Cushing triad

  • CSF rhinorrhea or CSF otorrhea
  • Haemotympanum or blood visible at the external auditory meatus if the tympanic membrane has ruptured
  • Ecchymosis behind the ear (Battle sign) or in the periorbital area (raccoon eyes)



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