Tiered therapy reduces secondary injury — escalate stepwise from sedation to surgery
Surgical evidence
Contusion evacuation >25 mL — generally accepted indication, though RCT data limited
DECRA trial — early decompressive craniectomy reduced ICP but increased unfavorable outcomes in diffuse TBI
RESCUEicp trial — decompressive craniectomy reduced mortality but increased vegetative state rate in refractory ICP
Posterior fossa contusions — surgical threshold lower due to limited space and risk of rapid brainstem compression
Anticoagulation reversal evidence
Rapid reversal reduces hematoma expansion and improves outcomes — Level B recommendation
4-factor PCC superior to fresh frozen plasma for speed of reversal and volume
Idarucizumab for dabigatran — complete reversal within minutes (RE-VERSE AD trial)
Routine platelet transfusion for antiplatelet reversal not recommended — PATCH trial showed harm
Neuroprotection and emerging therapies
No proven pharmacological neuroprotective agent in TBI to date
Progesterone — failed to show benefit in PROTECT III and SyNAPSe trials
Biomarkers — GFAP and UCH-L1 validated in FDA-cleared blood tests for mild TBI (Banyan BTI)
S100B — used in Scandinavian guidelines to stratify CT need in mild TBI
Restart anticoagulation 14–90 days post-TBI depending on thrombotic vs. bleeding risk balance
Restart antiplatelet agents as early as 4 days post-injury if hemorrhage is stable
Patient Discharge Instructions
copy discharge instructions
Discharge instructions for cerebral contusion
Your injury
You have been diagnosed with a cerebral contusion — a bruise of the brain from head injury
This type of injury can change over the first 24–48 hours — follow-up is important
You must not be left alone tonight — a responsible adult must stay with you
Activity restrictions
No driving for at least 24 hours or while taking pain medications
No alcohol or recreational drugs — these worsen brain injury and hide important symptoms
No return to contact sports or strenuous activity until cleared by your doctor
Rest today — limit screen time, reading, and activities that worsen headache
Return to school or work only when symptoms resolve and with medical guidance
Medications
Use acetaminophen (Tylenol) for headache — do not use ibuprofen, aspirin, or naproxen
Take all prescribed medications including seizure medications exactly as directed
Do not restart blood thinners without specific instructions from your doctor
Return to emergency department immediately if
Headache that is worsening or severe
Vomiting more than once
Increasing confusion, difficulty waking, or unusual drowsiness
Weakness or numbness in arm or leg
Seizure activity
Clear fluid from nose or ears
Vision changes, double vision, or slurred speech
Unsteady walking or new falls
Behavioral changes or agitation
Follow-up
Neurosurgery or neurology appointment in 2–4 weeks — call to confirm
If symptoms worsen before follow-up, go to the emergency department
Symptoms such as headache, difficulty concentrating, fatigue, and sleep problems can last weeks — this is expected with post-concussive syndrome
References
Guidelines and key sources
Brain Trauma Foundation
Brain Trauma Foundation Guidelines for the Management of Severe TBI, 4th edition
Provides Level IIB recommendation for ICP monitoring in GCS 3–8 with abnormal CT
American College of Surgeons
Best Practices in the Management of Traumatic Brain Injury, ACS 2024 (Manley et al.)
Best Practices Guidelines in Imaging, ACS 2018 (Tominaga et al.)
ACEP Clinical Policy
Valente JH et al. Clinical Policy: Critical Issues in the Management of Adult Patients with Mild TBI, Ann Emerg Med 2023
ACEP Board of Directors approval February 1, 2023; endorsed by Emergency Nurses Association
ACR Appropriateness Criteria
Expert Panel on Neurological Imaging, Shih RY et al. ACR Appropriateness Criteria Head Trauma: 2021 Update, J Am Coll Radiol 2021
Landmark trials
Contusion outcomes and expansion
Iaccarino C et al. Patients with Brain Contusions: Predictors of Outcome and Relationship Between Radiological and Clinical Evolution. J Neurosurg 2014
Smith PD et al. Predictive Factors for Traumatic Cerebral Contusion Volume, Expansion, and Outcomes. J Neurosurg 2025
Zhu Y et al. Establishment and Validation of Prognosis Model for Patients with Cerebral Contusion. BMC Neurol 2021
Tranexamic acid
CRASH-3 trial collaborators. Effects of TXA on Death, Disability, Vascular Occlusive Events in Acute TBI. Lancet 2019
Lawati KA et al. Efficacy and Safety of TXA in Acute TBI: Systematic Review and Meta-Analysis. Intensive Care Med 2021
Zhang M, Liu T. Efficacy and Safety of TXA in Acute TBI: Meta-Analysis of RCTs. Am J Emerg Med 2024
Bossers SM et al. Association Between Prehospital TXA Administration and Outcomes of Severe TBI. JAMA Neurol 2021
Anticoagulation reversal
Maegele M et al. Coagulopathy and Haemorrhagic Progression in TBI. Lancet Neurol 2017
Popma E et al. Reversal of Antithrombotic Medications in Patients with TBI. J Trauma Acute Care Surg 2025
Seizure prophylaxis
Chang BS, Lowenstein DH. Practice Parameter: Antiepileptic Drug Prophylaxis in Severe TBI. Neurology 2003
Surgical evidence
Cooper DJ et al. DECRA Trial — Decompressive Craniectomy in Diffuse TBI. NEJM 2011
Hutchinson PJ et al. RESCUEicp Trial — Decompressive Craniectomy in Refractory ICP. NEJM 2016
Imaging and decision rules
Easter JS et al. Will Neuroimaging Reveal Severe Intracranial Injury in Minor Head Trauma? JAMA 2015
Yuh EL et al. Pathological CT Features Associated with Adverse Outcomes After Mild TBI: TRACK-TBI Study. JAMA Neurol 2021
Rubino S et al. Outpatient Follow-Up of Nonoperative Cerebral Contusion and tSAH: Does Repeat CT Alter Management? J Neurosurg 2014
Geriatric TBI
Depreitere B et al. Unique Considerations in Assessment and Management of TBI in Older Adults. Lancet Neurol 2025
Neurological assessment
Maas AI, Stocchetti N, Bullock R. Moderate and Severe TBI in Adults. Lancet Neurol 2008
Levin HS, Diaz-Arrastia RR. Diagnosis, Prognosis, and Clinical Management of Mild TBI. Lancet Neurol 2015
Menon DK et al. Clinical Assessment on Days 1–14 for Characterization of TBI. J Neurotrauma 2025
Silverberg ND et al. Action Collaborative on TBI Care: Adapted Clinical Practice Guideline. Ann Fam Med 2025
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.