Traumatic brain injury classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]


Traumatic brain injury may be classified into several subtypes including focal or diffuse, open or close, and mild, moderate or severe.


  • Focal vs. Diffuse
    • The damage from TBI can be focal, confined to one area of the brain, or diffuse, involving more than one area.
    • Diffuse trauma to the brain is frequently associated with concussion (a shaking of the brain in response to sudden motion of the head), diffuse axonal injury, or coma.
    • Localized injuries may be associated with neurobehavioral manifestations, hemiparesis or other focal neurologic deficits.
    • Types of focal brain injury include bruising of brain tissue called a contusion and intracranial hemorrhage or hematoma, heavy bleeding in the skull.
    • Hemorrhage, due to rupture of a blood vessel in the head, can be extra-axial, meaning it occurs within the skull but outside of the brain, or intra-axial, occurring within the brain.
    • Extra-axial hemorrhages can be further divided into subdural hematoma, epidural hematoma, and subarachnoid hemorrhage.
    • An epidural hematoma involves bleeding into the area between the skull and the dura.
    • With a subdural hematoma, bleeding is confined to the area between the dura and the arachnoid membrane.
    • A subarachnoid hemorrhage involves bleeding into the space between the surface of the brain and the arachnoid membrane that lies just above the surface of the brain, usually resulting from a tear in a blood vessel on the surface of the brain.
    • Bleeding within the brain itself is called an intracerebral hematoma.
    • Intra-axial bleeds are further divided into intraparenchymal hemorrhage which occurs within the brain tissue itself and intraventricular hemorrhage which occurs into the ventricular system.[1]
  • Open vs. Closed
    • TBI can result from a closed or penetrating head injury.
    • A closed injury occurs when the skull is not breached, while a penetrating injury occurs when an object pierces the skull and enters brain tissue.
    • As the first line of defense, the skull is particularly vulnerable to injury.
    • Skull fractures occur when a bone in the skull cracks or breaks.
    • A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain.
    • A penetrating skull fracture occurs when something pierces the skull, such as a bullet, leaving a distinct and localized traumatic injury to brain tissue.
    • Skull fractures can cause cerebral contusion.
  • Severity
    • Head injuries can be subdivided into mild, moderate, and severe TBI to help predict outcome.
    • One common classification system determines severity based on the Glasgow Coma Scale (GCS) and duration of post-traumatic amnesia (PTA) and loss of consciousness (LOC) according to the table at right.
    • Other classification systems use GCS alone or PTA or LOC alone or together.
    • Prognosis worsens with the severity of injury, but mild TBI is more poorly defined and prognosis is not as clear with it.
    • Mild TBI is also commonly called concussion.
    • Though prognosis for concussion is usually very good, a portion of people may suffer lasting problems associated with the injury, such as post-concussion syndrome.
    • A patient who receives a second concussion before symptoms from another one have healed is at risk for developing a very rare but deadly condition called second-impact syndrome, in which the brain swells catastrophically after even a mild blow.[2]
Levels of TBI severity
Mild 13 to 15 <1
Moderate 9 to 12 30 minutes
to 24 hours
1 to 24
Severe <8 >1 day >24


  1. Saatman KE, Duhaime AC, Bullock R, Maas AI, Valadka A, Manley GT; et al. (2008). "Classification of traumatic brain injury for targeted therapies". J Neurotrauma. 25 (7): 719–38. doi:10.1089/neu.2008.0586. PMC 2721779. PMID 18627252.
  2. O'Neil ME, Carlson K, Storzbach D, et al. Complications of Mild Traumatic Brain Injury in Veterans and Military Personnel: A Systematic Review [Internet]. Washington (DC): Department of Veterans Affairs (US); 2013 Jan. Table A-1, Classification of TBI Severity. Available from:

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