What Comes After The Crash: Be Aware Of The Head Injury You Cannot See

KUALA LUMPUR, May 12 (Bernama) -- Head injuries are among the most concerning outcomes of road traffic accidents, ranging from mild concussions to serious brain trauma and skull fractures.

Consultant Emergency Physician at Sunway Medical Centre Velocity (SMCV), Dr Cyrus Lai Sin Nan, in a statement, said road traffic accidents remain one of the leading causes of traumatic brain injury in Malaysia and globally.

He noted that these injuries can happen through a direct hit to the head, the sudden force of the body being thrown forward and back, or rotational movement during impact, with some cases involving brain bleeding or skull fractures that require urgent intervention.

“A patient may look well initially and still have internal bleeding, brain swelling, or a skull fracture. Serious head injuries can evolve over hours, which is why symptoms and neurological status must be monitored closely,” he said.

However, he said not all head injuries carry the same level of risk, as they may present across a wide spectrum from concussion to brain trauma and skull fracture. A concussion can temporarily affect brain functions, while more serious injuries may involve bleeding or swelling in the brain. Skull fractures occur when the impact is strong enough to crack or break the bone protecting the brain.

Dr Cyrus explains that head injuries may involve primary injury, where the brain is affected at the moment of impact through direct force, acceleration-deceleration movement or rotational shear, as well as secondary injury, where complications such as cerebral oedema (brain swelling), hypoxia, (lack of oxygen), or hypotension (low blood pressure that reduces blood flow to the brain), worsen the initial trauma.

This makes head injuries difficult to judge based on the appearance of the accident alone, as even a less dramatic collision can still affect brain function, he said.

Meanwhile, according to Consultant Neurosurgeon at SMCV, Dr Mah Jon Kooi, what separates these injuries is not always how the patient appears immediately after the accident, but whether there is structural damage, pressure on the brain or the need for urgent intervention.

He said even without visible bleeding or an open wound, the soft brain tissue can still jolt inside the rigid skull during an impact, causing injury at a cellular and functional level, while concussions can occur even in lower-velocity collisions due to rotational forces on the brain, although skull fractures are more commonly linked to high-impact crashes.

Although some head injuries may initially seem minor, certain symptoms can signal more serious brain trauma and require urgent medical attention, and early signs may include persistent headaches, confusion, memory lapses, or subtle changes in thinking and behaviour.

As the condition worsens, symptoms may become more serious, including repeated vomiting, worsening headaches, slurred speech, weakness or numbness, and difficulty with coordination. In more severe cases, warning signs include unequal pupil size, bleeding or fluid leaking from the nose or ears, seizures, and loss of consciousness.

It is also important to note that symptoms may not appear immediately after the accident. Individuals may seem well initially, only to develop warning signs hours later.

This delayed onset highlights the importance of close observation within the first 24 to 48 hours, with family members or caregivers monitoring for subtle changes such as confusion, unusual drowsiness, difficulty concentrating, or changes in speech and coordination, which may signal a more serious underlying issue.

Beyond physical symptoms, head injuries can also affect mood and behaviour, particularly when the frontal lobe is involved. Individuals may experience irritability, anxiety, depression, or changes in personality and self-control.

Most mild head injury symptoms improve within one to two weeks, but some may last for weeks or months, a condition known as post-concussional syndrome. In more severe cases, these effects can become long-term or permanent, highlighting the importance of early detection, proper monitoring, and timely medical care.

Once a head injury is suspected, the priority is no longer just whether the patient looks well, but whether the brain is being protected from further damage. 

In the Accident and Emergency (A&E) Department, assessment begins with stabilising the patient, protecting the cervical spine where needed, and checking the neurological functions through level of consciousness, pupil response and limb strength.

An imaging test may also be required, as Dr Cyrus noted that a CT scan may help detect bleeding, swelling or fractures that are not visible through clinical assessment alone, while from a neurosurgical perspective, Dr Mah said the most concerning complications are those that increase pressure within the skull.

“If bleeding expands or swelling worsens, blood flow to the brain may be restricted, increasing the risk of permanent neurological damage. The rigid skull allows for very little expansion, and excessive pressure can restrict blood flow to the brain, leading to ischemia (leading to ischemia, where reduced blood flow limits oxygen supply to the brain) and permanent damage,” Dr Mah said.

In severe cases, increased pressure in the brain can lead to brain herniation, where brain tissue is compressed and displaced, making early detection and close monitoring critical. Beyond bleeding and swelling, head injuries can also affect how a person thinks, speaks, moves, or behaves, depending on the area of the brain involved.

Dr Cyrus said the treatment of head injuries becomes more urgent when scans show bleeding, swelling or pressure affecting the brain and that patients who remain stable may be observed closely, while those with worsening neurological signs or pressure on the brain may require urgent neurosurgical review.

“If a patient is discharged, caregivers must continue monitoring for red flags such as worsening headache, repeated vomiting or increasing confusion, which should prompt immediate return to the Accident and Emergency (A&E) Department,” he added.

Dr Mah explains that surgery may be needed when bleeding expands, pressure rises, or the patient does not respond to initial treatment.

He said the priority is to relieve pressure, stop bleeding and prevent further damage to the brain. Beyond the acute phase, recovery may also involve rehabilitation to support physical, cognitive, and daily functional recovery, particularly for patients experiencing neurological or cognitive impairment.

People with mild head injuries often return to normal activities within one to two weeks, while those with moderate to severe injuries usually need a longer recovery period, often involving a structured rehabilitation programme, occupational therapy, and cognitive support.

In some severe cases, the effects may be long-lasting or permanent, affecting the patient’s independence, movement, or the ability to return to work. 

If head injuries such as concussion, brain trauma, or skull fractures are not treated promptly, the long-term consequences can be significant, which may include persistent cognitive impairment such as memory loss and difficulties with decision-making, as well as emotional and behavioural changes, including depression and personality shifts.

In addition, untreated head injuries may increase the risk of neurodegenerative conditions such as Alzheimer’s disease, chronic traumatic encephalopathy (CTE), and Parkinson’s disease.

For both consultants, the message is clear: “time is brain” when it comes to head injuries, and early diagnosis can prevent a seemingly minor injury from developing into a severe condition.

Following any significant head impact, especially after a road accident, seeking medical assessment early and monitoring symptoms closely can make a meaningful difference to recovery, long-term function and survival.

-- BERNAMA

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