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Medical complications after traumatic brain injury
When recovery of a brain-injured patient stalls or regresses, look for a treatable medical cause — hydrocephalus, seizures, a sodium disorder, pituitary insufficiency or drugs — and do not assume it is "the natural course".
Why it matters in the exam
Seizures: an early seizure occurs in the first week, and a late seizure — after the first week and defines post-traumatic epilepsy. Under the Brain Trauma Foundation, phenytoin (or levetiracetam) for the first seven days after severe injury reduces early seizures only and does not prevent late seizures, so it is not continued beyond a week without a seizure. Risk factors for late seizures: penetrating injury, depressed skull fracture, subdural haemorrhage or contusion, and an early seizure.
Paroxysmal sympathetic hyperactivity (PSH) occurs in severe injury, especially with DAI: episodes of tachycardia, hypertension, fever, sweating, rapid breathing and flexor or extensor posturing. Treatment: avoid triggers (pain, urinary retention), propranolol, gabapentin, clonidine, and during an episode — morphine. Post-traumatic hydrocephalus shows as a stall or regression in recovery and is diagnosed on CT; treatment is drainage (a shunt). Heterotopic ossification (HO) occurs mainly around the hip, elbow, shoulder and knee, with pain, local warmth and reduced range of motion.
Sodium: SIADH presents with hyponatraemia and normal volume and is treated by fluid restriction; cerebral salt wasting (CSW) presents with hyponatraemia, dehydration and high urine sodium, and is treated with fluids and salt (sometimes fludrocortisone) — volume status tells them apart. Central diabetes insipidus — large volumes of dilute urine with high blood sodium. Pituitary insufficiency is relatively common, and growth hormone deficiency is the common one; fatigue, lack of progress and hyponatraemia should raise suspicion of cortisol deficiency. Other complications: spasticity, venous thrombosis, swallowing problems, sleep disorders, depression and behavioural change.
Key points
- Seizure prophylaxis for 7 days only.
- PSH — sympathetic episodes; propranolol and gabapentin.
- Stalled recovery — look for hydrocephalus.
- SIADH versus CSW — volume status decides.
- Growth hormone deficiency is the common deficiency.
Summary table
| Complication | Clues | Treatment |
|---|---|---|
| Early seizures | In the first week | Phenytoin or levetiracetam for 7 days in severe injury |
| Post-traumatic epilepsy | Seizures after the first week | Long-term anti-seizure drug |
| PSH | Tachycardia, hypertension, fever, sweating, posturing | Propranolol, gabapentin, clonidine, morphine during an episode |
| Hydrocephalus | Stall or regression in recovery | CT and a shunt |
| SIADH versus CSW | Hyponatraemia; normal volume versus dehydration | Fluid restriction versus fluids and salt |
| Pituitary insufficiency | Fatigue, hyponatraemia, lack of progress | Hormone tests and replacement |
A free exam question
בן 18 נפגע בתאונת דרכים וסבל מחבל ה מוחית קשה. מהו הגורם המשפיע ביותר על מצבו ( התפקודי הכולל outcome ? ) שנה לאחר התאונה (the question as examined, in Hebrew)
- א. משך האמנזיה הבתר חבלתית
- ב. הממצאים בבדיקת הטומוגרפיה הממוחשבת הראשונה של הראש
- ג. קיום או העדר פרכוס מוקדם
- ד. מידת התמיכה המשפחתית
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Sources
- Brain Trauma Foundation: Guidelines for the Management of Severe Traumatic Brain Injury, 4th edition (2016) — Seizure prophylaxis
- Brain Injury Medicine: Principles and Practice, 3rd edition (2021) — Medical complications: paroxysmal sympathetic hyperactivity, hydrocephalus, heterotopic ossification and neuroendocrine dysfunction
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.