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EMERGENCY:Head injury with loss of consciousness, confusion, vomiting, weakness, or unequal pupils —call040-46324365immediately — 24 hours, 7 days— 24/7

TRAUMATIC NEUROLOGY

Traumatic Brain Injury in Hyderabad: The First Hour, the CT Decision, and the Surgery That Saves the Brain From Pressure — Emergency Neurosurgical Care at KIMS

24-hour emergency CT triage, ICP monitoring, craniotomy, decompressive craniectomy, and neurocritical ICU care at KIMS Neuroscience, Secunderabad, Hyderabad.

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TBI is damage to the brain from an external mechanical force. Classified by GCS at presentation: mild (GCS 13–15, concussion), moderate (GCS 9–12, may have haemorrhage or contusion), and severe (GCS 3–8, significant haemorrhage, contusion, or diffuse axonal injury). The most immediately dangerous complication is an expanding intracranial haematoma — particularly the extradural haematoma (EDH) from a torn middle meningeal artery, which produces the lucid interval: a period of apparent normality followed by rapid deterioration. CPP = MAP − ICP: target ICP <20–22 mmHg and CPP >60–65 mmHg. Surgical interventions: haematoma evacuation for focal bleeds causing mass effect; decompressive craniectomy when ICP cannot be controlled medically. At KIMS: immediate CT, neurosurgical review within 30 minutes, surgical decision within the hour for identified haematoma.

The lucid interval: A patient can be conscious and talking after a head injury and die within hours from an expanding extradural haematoma. EDH evacuated before herniation has an excellent outcome; EDH after herniation has a dramatically worse one.
Five CT haemorrhage types: EDH (biconvex/lens-shaped, arterial) · ASDH (crescent-shaped, venous, with underlying contusion) · ICH (intracerebral, can expand in first 24h) · tSAH (sulci, vasospasm risk) · Diffuse oedema (raised ICP throughout).
CPP = MAP − ICP: Target ICP <20–22 mmHg; CPP >60–65 mmHg; MAP >80 mmHg. When ICP rises above 20–25 mmHg and CPP falls below 60 mmHg, the brain is no longer adequately perfused. Monitored with Camino bolt or EVD.
Decompressive craniectomy: DECRA and RESCUEicp trials: craniectomy reduces ICP and saves lives but increases disability in survivors. Patient selection is critical. The KIMS Neuroscience team performs craniectomy when medical ICP management fails.
Anticoagulated elderly: Warfarin, rivaroxaban, apixaban, dabigatran: CT head for ANY head injury regardless of severity. Elderly anticoagulated patients develop EDH or SDH from impacts that would not cause haematoma in younger non-anticoagulated patients.
Canadian CT Head Rules: CT indicated if: GCS <15 at 2h · suspected open/depressed fracture · basal skull fracture signs · two or more vomiting episodes · age ≥65 · amnesia ≥30 min before impact · dangerous mechanism (pedestrian struck, fall >1m, vehicle ejection).
"Talk and die" patient: A patient with a traumatic intracerebral haematoma can be talking on arrival. ICH can expand rapidly in the first 24 hours. Any ICH patient who was talking and deteriorates needs immediate repeat CT and urgent surgical review.

Fact	Details
GCS severity	Mild TBI: GCS 13–15 · Moderate: GCS 9–12 · Severe: GCS 3–8 · Declining GCS is a surgical emergency
EDH	Biconvex collection · Middle meningeal artery tear · Lucid interval · Evacuation before herniation = excellent outcome · Delay = herniation, death, or permanent disability
ASDH	Crescent-shaped collection · Bridging vein tear · Associated with brain contusion · Higher mortality than EDH · Surgery if clot >10mm, midline shift >5mm, or GCS decline >2 points
CPP management	ICP target <20–22 mmHg · CPP target >60–65 mmHg · MAP target >80 mmHg · ICP monitoring: Camino bolt or EVD · Osmotherapy: mannitol or hypertonic saline
Decompressive craniectomy	Large skull section removed · Bone stored refrigerated or in abdominal fat · Cranioplasty at 3–6 months · DECRA + RESCUEicp: reduces mortality, increases disability in survivors · Critical patient selection
Anticoagulated elderly	CT head for ANY head injury regardless of mechanism severity · Elderly brain tolerates haematoma less well · Anticoagulation reversal at KIMS when indicated
Emerging biomarkers	GFAP, UCH-L1, S100B: emerging blood biomarkers for mild TBI triage · Adjuncts to CT decision-making

About This Condition

The Lucid Interval

A 34-year-old construction worker in Secunderabad falls from scaffolding and strikes his right temple on a metal beam. He is conscious at the scene, complains of headache, and is brought to KIMS by ambulance. His GCS on arrival is 14 (confused, but speaking in sentences and following commands). His family says he briefly lost consciousness for about a minute at the scene.

The brief loss of consciousness + head trauma + headache satisfies the Canadian CT Head Rules for imaging. CT head is done within 20 minutes of arrival. It shows a lens-shaped (biconvex) hyperdense collection between the inner table of the right temporal bone and the dura mater, measuring 2.8 cm at its thickest point, with 6 mm of midline shift. This is an extradural haematoma (EDH) — blood from a torn right middle meningeal artery accumulating between the skull and dura, compressing the right temporal lobe and pushing the brain leftward.

While the CT is being reviewed, the patient's GCS falls from 14 to 10 — he is now drowsy and no longer following commands reliably. This is the lucid interval closing. the KIMS Neuroscience team is called immediately. The decision is made: emergency right temporal craniotomy and haematoma evacuation. The patient is in theatre within 45 minutes of arrival at KIMS. The haematoma is evacuated, the bleeding vessel is coagulated, and the bone flap is replaced.

At 24-hour review: GCS 15, full power in all limbs, pupils equal and reactive. He is discharged on day 5 with no neurological deficit. The outcome of extradural haematoma surgery, when performed before the patient loses consciousness, is excellent. The outcome when surgery is delayed until coma is established is dramatically worse. This is why the first hour matters.

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Speak directly with The KIMS Neuroscience team's neurosurgical trauma team. 24-hour emergency surgery available. Monday to Saturday for outpatients.

040-44885000Emergency line: 040-46324365

Key Facts

Quick Facts about Traumatic Brain Injury

The essential context: what TBI is, the leading causes in India, why the first hour matters, and how the GCS classifies severity.

What it is

Traumatic brain injury (TBI) is damage to the brain caused by an external mechanical force — a blow to the head, a penetrating object, or the deceleration forces of a road accident. TBI encompasses everything from a mild concussion (no structural damage, full recovery expected) to devastating multi-focal haemorrhage requiring emergency surgery. The immediate priority in any significant head injury is to determine whether there is bleeding or pressure building inside the skull — because unrecognised and untreated raised intracranial pressure (ICP) kills or permanently disables.

The leading cause in India

Road traffic accidents cause the great majority of moderate and severe TBIs in India — and Hyderabad's roads, with their high density of two-wheelers and mixed traffic, produce a significant TBI burden. Two-wheeler crashes without helmets are the most common mechanism for fatal TBI in India. Falls from height (construction workers, roof falls) are the second most common cause. Assault, sports injuries, and diving accidents complete the spectrum.

Why the first hour matters

The 'golden hour' concept in trauma is specifically relevant to TBI. A patient with an expanding extradural haematoma (blood collecting between the skull and the dura from a torn middle meningeal artery) can be fully conscious on arrival at hospital and dead within hours if the haematoma is not evacuated. This 'lucid interval' — a period of apparent recovery followed by rapid deterioration — is the most treatable neurosurgical emergency. At KIMS, the protocol is: immediate CT head; neurosurgical review within 30 minutes of CT; surgical decision within the hour if haematoma is identified.

Glasgow Coma Scale (GCS)

The GCS is the universal language of TBI severity. It scores three responses: Eye opening (1–4), Verbal response (1–5), and Motor response (1–6). Total score ranges from 3 (no response) to 15 (fully alert). Mild TBI: GCS 13–15. Moderate TBI: GCS 9–12. Severe TBI: GCS 3–8. The GCS is recorded at scene, on arrival, and serially through the acute phase at KIMS. A declining GCS is a surgical emergency.

Treatment

TBI Severity Classification and Management

The Glasgow Coma Scale stratifies TBI into mild, moderate, and severe — and each level has a defined acute management and rehabilitation pathway at KIMS.

GCS 13–15

Mild TBI / Concussion

Definition & CT

Brief or no LOC (<30 min); PTA <24 hours; normal CT head

Acute management at KIMS

No routine imaging unless the Canadian CT Head Rules (CCHR) or New Orleans Criteria are met; observe for 4–6 hours if high-risk features; discharge with head injury advice sheet; no driving for 24 hours; follow-up at 2 weeks

Rehabilitation

Return to activity protocol; concussion clinic if symptoms persist >4 weeks

GCS 9–12

Moderate TBI

Definition & CT

LOC 30 min–24 hours; PTA 1–24 hours; CT may show contusion or haemorrhage

Acute management at KIMS

Admission to hospital; CT head; hourly GCS observations; repeat CT at 12–24 hours; neurosurgical consultation; consider ICP monitoring

Rehabilitation

Inpatient rehabilitation; neuropsychological assessment; outpatient follow-up

GCS 3–8

Severe TBI

Definition & CT

LOC >24 hours; GCS ≤8; CT typically shows significant haemorrhage, contusion, or DAI

Acute management at KIMS

Emergency CT; ICP monitoring (Camino bolt or EVD); MAP ≥80 mmHg; SpO2 >95%; surgical intervention if indicated (haematoma evacuation, decompressive craniectomy); neurocritical ICU care

Rehabilitation

Prolonged inpatient rehabilitation; DOC programme if persistent coma/vegetative state

Recognising Intracranial Bleeding

Types of Intracranial Haemorrhage

The CT pattern distinguishes the haemorrhage type — and the type determines the urgency, the surgical approach, and the prognosis.

Extradural haematoma (EDH) — the most treatable emergency

Blood collects between the skull and the dura mater, typically from a torn middle meningeal artery after a temporal or parietal skull fracture. CT appearance: biconvex (lens-shaped) hyperdense collection. The lucid interval is characteristic: loss of consciousness at impact, then apparent recovery, followed by rapid deterioration as the haematoma expands. EDH is a true neurosurgical emergency — evacuation before herniation produces excellent outcomes. Delay produces herniation, uncal herniation, and death or permanent disability. At KIMS, EDH with midline shift or significant volume is evacuated within 1 hour of diagnosis.

Acute subdural haematoma (ASDH) — the high-mortality injury

Blood collects between the dura and the arachnoid, typically from tearing of bridging veins crossing the subdural space. CT appearance: crescentic (crescent-shaped) hyperdense collection following the brain's contour. ASDH has higher mortality than EDH because it is often associated with underlying brain contusion and cerebral oedema. The brain injury is not just from the clot but from the underlying parenchymal damage. Indications for surgery (craniotomy and haematoma evacuation or decompressive craniectomy): clot thickness >10mm, midline shift >5mm, or GCS decline >2 points. At KIMS, ASDH with mass effect is operated as an emergency.

Intracerebral haematoma (ICH) from trauma

Blood within the brain parenchyma itself, from direct contusion and laceration of brain vessels. Often multiple and irregular in shape on CT. Small ICHs from contusion are managed conservatively with serial CT monitoring; large ICHs causing mass effect or neurological deterioration are evacuated. The 'talk and die' patient — conscious on arrival but with a significant ICH — requires close monitoring at KIMS with repeat CT at 6 hours (as traumatic ICH can expand rapidly in the first 24 hours).

Traumatic subarachnoid haemorrhage (tSAH)

Blood in the subarachnoid space (the fluid-filled space around the brain) from traumatic rupture of small cortical vessels. CT shows hyperdense blood in the sulci and fissures. tSAH increases the risk of delayed cerebral vasospasm (like aneurysmal SAH but less severe). At KIMS, patients with tSAH are monitored for vasospasm and neurological deterioration. Nimodipine is given in severe tSAH to reduce vasospasm risk.

Diffuse cerebral oedema — the swelling that kills

After severe TBI, the brain can swell diffusely — from cellular oedema, vascular congestion, and metabolic failure. This swelling raises intracranial pressure (ICP) throughout the skull, compressing all brain tissue equally and reducing cerebral perfusion pressure (CPP = MAP − ICP). When ICP rises above 20–25 mmHg and CPP falls below 60 mmHg, the brain is no longer adequately perfused. Sustained elevated ICP causes progressive brain injury and eventually brain death from herniation. At KIMS, severe TBI with suspected raised ICP is managed with ICP monitoring (Camino bolt or external ventricular drain, EVD), head-of-bed elevation to 30 degrees, osmotherapy (mannitol or hypertonic saline), and decompressive craniectomy when medical ICP management fails.

Neurosurgical Care

Neurosurgical Procedures at KIMS

The KIMS Neuroscience team's 24-hour emergency neurosurgical service performs the full range of TBI procedures — from haematoma evacuation to decompressive craniectomy and ICP monitoring.

Craniotomy and Haematoma Evacuation

The standard surgical approach for extradural, subdural, or intracerebral haematomas causing mass effect: a section of skull (bone flap) is temporarily removed, the haematoma is evacuated under direct vision or with neuronavigation guidance, the bleeding source is controlled, and the bone flap is replaced. Duration: 2–4 hours depending on haematoma size and complexity. At KIMS, The KIMS Neuroscience team performs craniotomy for acute traumatic haematomas 24 hours a day.

Decompressive Craniectomy

When ICP cannot be controlled with medical therapy despite optimal management, or when the brain is so swollen at the time of haematoma evacuation that replacing the bone flap would re-compress the brain, decompressive craniectomy is performed: a large section of skull is removed and not replaced. The dura is opened and patched with a graft, giving the brain space to swell outward rather than compressing inward. The bone flap is stored (in a refrigerated bone bank or implanted in the patient's abdominal fat) and cranioplasty (replacing the bone) is performed 3–6 months later when the brain swelling has settled. Evidence from the DECRA and RESCUEicp trials: decompressive craniectomy reduces ICP and saves lives but is associated with increased disability in survivors; patient selection is critical.

External Ventricular Drain (EVD) and ICP Monitoring

For patients with severe TBI, ICP is monitored continuously at KIMS using either: an EVD (a catheter placed into the lateral ventricle, which both measures ICP and allows CSF drainage to lower pressure) or an intraparenchymal monitor (Camino bolt, placed directly into brain tissue to measure pressure without drainage capability). ICP is maintained below 20–22 mmHg; CPP is maintained above 60–65 mmHg by adjusting blood pressure (target MAP >80 mmHg) and ICP simultaneously.

Skull Fracture Management

Simple linear skull fractures without depression: conservative management, no surgery. Depressed skull fractures (where the fractured bone is pushed inward, compressing the brain below): surgical elevation if the depression exceeds the skull thickness, if the dura is torn (open fracture), or if there is underlying haematoma. Compound fractures (open, with scalp laceration overlying the fracture): surgical debridement and repair to prevent infection (osteomyelitis, meningitis).

Related Conditions

Traumatic brain injury belongs to the family of traumatic neurological conditions managed at KIMS:

Concussion & Mild TBI Post-Concussion Syndrome Diffuse Axonal Injury Spinal Cord Injury Traumatic Encephalopathy

FAQs

Frequently Asked Questions

Yes — immediately. Being conscious and talking does not mean there is no serious brain injury. The most dangerous intracranial haematoma — the extradural haematoma — classically presents with a period of apparent normality (the lucid interval) after a brief loss of consciousness, before the expanding blood clot causes sudden deterioration. A person who seems fine at the accident scene can be in coma within 1–2 hours from an undiagnosed expanding haematoma. At KIMS, the CT head decision is made immediately on arrival using the Canadian CT Head Rules: any head injury with brief loss of consciousness, vomiting, amnesia for the event, age over 65, or dangerous mechanism (motorcycle crash, fall from height) gets an immediate CT. Do not wait and watch at home. Call 040-46324365 and come to KIMS emergency now.

A decompressive craniectomy is performed when the brain is so swollen that it is in danger of being crushed inside the rigid skull — a situation where the pressure inside the skull is rising so fast that medications are not controlling it. By removing a large section of the skull, the brain is given room to swell outward harmlessly rather than being compressed inward, which would destroy the brainstem. The removed bone is stored and replaced in a second operation (cranioplasty) 3–6 months later when the brain has recovered and the swelling has settled. The craniectomy is a life-saving procedure in a situation where without it, your father would almost certainly die or suffer devastating brain damage from the uncontrolled pressure. the KIMS Neuroscience team at KIMS performs this procedure and will explain the specific indications and expected outcomes for your father's situation. Call 040-46324365.

Come to KIMS emergency immediately — call 040-46324365. Worsening headache and increasing drowsiness appearing days after a head injury can indicate delayed bleeding or swelling inside the skull. A small haemorrhage or contusion that was stable in the first 24 hours can enlarge over the first 2–3 days, particularly in older patients on blood-thinning medication or in patients with more severe initial injuries. This is not a symptom to watch and wait. At KIMS, repeat CT head is arranged urgently; if there is new or enlarging haemorrhage, emergency neurosurgical review determines whether intervention is needed. Please do not delay.

Both are blood clots inside the skull compressing the brain, but they differ in location, cause, and urgency. Extradural haematoma (EDH): blood between the skull and the dura mater, usually from a torn artery (middle meningeal artery after temporal bone fracture). Seen in younger patients. The blood source is arterial so it expands rapidly. Classic lucid interval presentation. When evacuated before brain herniation, EDH has an excellent outcome. Subdural haematoma (ASDH): blood between the dura and the brain surface, from torn bridging veins. Can be acute (after severe trauma) or chronic (in elderly patients after minor trauma, sometimes forgotten). Acute ASDH is often associated with underlying brain contusion, making the prognosis worse than EDH even with surgery. Chronic SDH in elderly patients: a separate condition requiring separate management. At KIMS, the CT head appearance distinguishes them immediately: EDH is biconvex (lens-shaped); SDH is crescent-shaped. Both are managed surgically when causing significant mass effect. Call 040-46324365.

Yes — anyone on anticoagulants (warfarin, rivaroxaban, apixaban, dabigatran) or antiplatelet drugs (aspirin, clopidogrel) who sustains any head injury, even a minor one, should have a CT head at KIMS. The reason: blood thinners suppress the normal clotting mechanism. A small vessel that would normally seal itself after a minor head impact continues to bleed, and the subdural or extradural haematoma that a younger, non-anticoagulated patient would not develop can form and expand in an elderly anticoagulated patient from an apparently trivial fall. Additionally, the elderly brain, which has already shrunk slightly with age, tolerates haematoma formation less well — the bridging veins crossing the subdural space are longer and more prone to tearing. At KIMS, elderly anticoagulated patients with any head injury are assessed with CT and anticoagulation reversal is considered when indicated. Please call 040-44885000 or come to KIMS emergency 040-46324365.

A head injury is not always obvious. The person who walks into KIMS talking and then deteriorates in the waiting room. The motorcyclist without a helmet who seemed fine at the scene. The 78-year-old on warfarin who bumped his head getting out of the car.

At KIMS Neuroscience, Secunderabad, Hyderabad, CT triage, neurosurgical assessment, haematoma evacuation, decompressive craniectomy, and ICP monitoring are available 24 hours a day. Emergency: 040-46324365. Appointments: 040-44885000.

040-44885000

International enquiries: info@kimsneurosciences.com