Traumatic Brain Injury: Concussion, Hematomas, Contusion, and Diffuse Axonal Injury Practice Questions

25 multiple-choice questions on Traumatic brain injury: concussion, hematomas, contusion, and diffuse axonal injury for paramedic and EMT students, from Chapter 35 (Head and Spine Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. Secondary brain injury refers to damage that:

   1. A. Follows the impact from hypoxia, hypotension, or swelling
   2. B. Occurs at the moment of impact from direct tissue tearing
   3. C. Develops when a second blow strikes the head later
   4. D. Results from a skull fracture rather than from the brain
   Show answer

   Answer: A. Follows the impact from hypoxia, hypotension, or swelling

   Primary injury happens at impact and cannot be reversed by EMS; secondary injury evolves over minutes to days from hypoxia, hypotension, raised ICP, and other insults. Preventing it is the main goal of prehospital TBI care.

2. The prehospital insults that most consistently worsen outcome after TBI are:

   1. A. Hypertension and fever
   2. B. Hyperglycemia and pain
   3. C. Hypoxia and hypotension
   4. D. Tachycardia and anxiety
   Show answer

   Answer: C. Hypoxia and hypotension

   Even a single episode of low oxygen saturation or low blood pressure is linked to markedly higher mortality after TBI. Fever and hyperglycemia are harmful too, but EMS has the most impact by preventing hypoxia and hypotension.

3. A concussion is best described as a traumatic brain injury that:

   1. A. Disturbs brain function without a visible lesion on CT
   2. B. Requires at least a brief loss of consciousness
   3. C. Produces a small hematoma beneath the dura
   4. D. Causes permanent loss of memory for the event
   Show answer

   Answer: A. Disturbs brain function without a visible lesion on CT

   Concussion is a mild TBI in which function is disrupted, with confusion, amnesia, headache, or dizziness, while standard imaging is usually normal. Loss of consciousness is not required for the diagnosis.

4. A 16-year-old soccer player collided heads with an opponent. She did not lose consciousness but is dazed, has a headache, and keeps asking what the score is. The most likely diagnosis is:

   1. A. Epidural hematoma
   2. B. Diffuse axonal injury
   3. C. Basilar skull fracture
   4. D. Concussion
   Show answer

   Answer: D. Concussion

   Confusion, repetitive questioning, and headache after a head impact without loss of consciousness are typical of concussion. An epidural hematoma usually involves loss of consciousness and progressive decline, and DAI causes prolonged coma.

5. The inability to form new memories after an injury, causing a patient to ask the same questions repeatedly, is called:

   1. A. Retrograde amnesia
   2. B. Expressive aphasia
   3. C. Anterograde amnesia
   4. D. Transient global ataxia
   Show answer

   Answer: C. Anterograde amnesia

   Anterograde amnesia affects events after the injury, so the patient cannot retain what you tell him. Retrograde amnesia is loss of memory for events before the injury, such as the drive leading up to a crash.

6. An epidural hematoma is most often caused by:

   1. A. Venous bleeding between the dura and arachnoid
   2. B. Arterial bleeding between the dura and the skull
   3. C. Bleeding into the brain tissue from contusions
   4. D. Bleeding into the CSF beneath the arachnoid
   Show answer

   Answer: B. Arterial bleeding between the dura and the skull

   An epidural hematoma usually results from a torn middle meningeal artery after a temporal fracture, so it can expand quickly. Venous bleeding beneath the dura describes a subdural hematoma.

7. A 19-year-old was struck on the temple with a baseball and briefly lost consciousness. He woke up, was talking normally, and refused care. Thirty minutes later he is drowsy and his right pupil is dilated. This sequence suggests:

   1. A. An epidural hematoma
   2. B. A chronic subdural hematoma
   3. C. A simple concussion
   4. D. A cerebral contusion
   Show answer

   Answer: A. An epidural hematoma

   A brief loss of consciousness followed by a lucid interval and then rapid decline is the classic pattern of arterial epidural bleeding. Concussion does not cause a delayed decline with a blown pupil.

8. A subdural hematoma most often results from tearing of the:

   1. A. Middle meningeal artery in the temporal bone
   2. B. Vertebral arteries at the base of the skull
   3. C. Bridging veins between the brain and dura
   4. D. Choroid plexus inside the lateral ventricles
   Show answer

   Answer: C. Bridging veins between the brain and dura

   Bridging veins cross the subdural space and tear with acceleration and deceleration, producing a slower venous bleed. The middle meningeal artery is the classic source of epidural hematoma.

9. Acute subdural hematomas carry a higher mortality than epidural hematomas mainly because they:

   1. A. Usually arise from a major arterial source such as the carotid
   2. B. Are usually accompanied by underlying brain injury
   3. C. Cannot be removed surgically once formed
   4. D. Occur mainly in patients on anticoagulants
   Show answer

   Answer: B. Are usually accompanied by underlying brain injury

   The force that tears bridging veins also bruises and shears the brain beneath, so outcome depends on that underlying damage. Epidural hematomas often occur with less injured brain, so prompt surgery can produce good recovery.

10. A 78-year-old with a history of alcohol use disorder fell in his kitchen 3 weeks ago. His family reports he has become increasingly confused and sleepy, with a worsening headache. You should suspect:

    1. A. An acute epidural hematoma
    2. B. Diffuse axonal injury
    3. C. Concussion recovery
    4. D. A chronic subdural hematoma
    Show answer

    Answer: D. A chronic subdural hematoma

    Brain atrophy from age and alcohol stretches the bridging veins, so minor trauma can start a slow venous bleed that becomes symptomatic weeks later. Epidural hematomas are arterial and present within hours.

11. Diffuse axonal injury is caused mainly by:

    1. A. A focal blow that fractures the skull vault
    2. B. Slow venous bleeding into the subdural space over several days
    3. C. Rotational acceleration that shears nerve fibers
    4. D. Penetration of brain tissue by a projectile
    Show answer

    Answer: C. Rotational acceleration that shears nerve fibers

    Rapid rotational or acceleration-deceleration forces stretch and tear axons throughout the brain. It is a diffuse injury without a single mass lesion, unlike a hematoma.

12. After a high-speed rollover, a 24-year-old has been unresponsive with a GCS of 5 since the crash. CT later shows no hematoma or mass lesion. The most likely injury is:

    1. A. Epidural hematoma
    2. B. Diffuse axonal injury
    3. C. Simple concussion
    4. D. Chronic subdural hematoma
    Show answer

    Answer: B. Diffuse axonal injury

    Immediate, prolonged coma after high-energy deceleration without a mass lesion on CT is characteristic of DAI. A simple concussion does not produce prolonged deep coma.

13. A driver's forehead strikes the windshield, and the brain is bruised both at the front and at the back of the head. This pattern is called:

    1. A. Coup-contrecoup injury
    2. B. Diffuse axonal injury
    3. C. Uncal herniation
    4. D. Second impact syndrome
    Show answer

    Answer: A. Coup-contrecoup injury

    The coup lesion occurs at the point of impact, and the contrecoup lesion forms on the opposite side as the brain rebounds against the skull. DAI is shearing of axons rather than bruising at two poles.

14. A cerebral contusion is best defined as:

    1. A. A collection of blood above the dura mater
    2. B. A tear of the bridging veins below the dura
    3. C. A temporary loss of function without injury
    4. D. Bruising of brain tissue with small bleeds
    Show answer

    Answer: D. Bruising of brain tissue with small bleeds

    A contusion is bruised brain with capillary bleeding and edema, most often in the frontal and temporal lobes. It can swell over the following days and raise ICP, unlike concussion, which has no structural lesion.

15. A 35-year-old has a sudden severe headache, neck stiffness, and vomiting after being struck in the head. CT shows blood in the CSF spaces around the brain. This is a:

    1. A. Chronic subdural hematoma with rebleeding
    2. B. Traumatic subarachnoid hemorrhage
    3. C. Acute epidural hematoma
    4. D. Diffuse axonal injury
    Show answer

    Answer: B. Traumatic subarachnoid hemorrhage

    Blood in the subarachnoid space irritates the meninges and causes headache and nuchal rigidity. Trauma is the most common cause of subarachnoid blood, though the presentation resembles an aneurysm rupture.

16. Bleeding within the brain tissue itself, often from deep contusions or penetrating injury, is called:

    1. A. Intracerebral hemorrhage
    2. B. Epidural hematoma
    3. C. Subdural hematoma
    4. D. Subgaleal hematoma of the scalp
    Show answer

    Answer: A. Intracerebral hemorrhage

    An intracerebral hemorrhage lies within the parenchyma, and its effects depend on its size and location. Subgaleal bleeding lies outside the skull, beneath the galea of the scalp.

17. A patient with an expanding left-sided epidural hematoma is most likely to show:

    1. A. Right pupil dilation and right-sided weakness
    2. B. Left pupil dilation and left-sided weakness
    3. C. Left pupil dilation and right-sided weakness
    4. D. Bilateral pinpoint pupils and no weakness
    Show answer

    Answer: C. Left pupil dilation and right-sided weakness

    The oculomotor nerve is compressed on the side of the mass, dilating that pupil, while motor tracts cross in the brainstem, so weakness appears on the opposite side. Weakness on the same side can occur but is not the usual pattern.

18. Gunshot wounds to the brain are especially lethal because the bullet:

    1. A. Usually remains outside the dura and causes bleeding
    2. B. Causes only a narrow track the width of the bullet
    3. C. Rarely raises intracranial pressure inside the skull
    4. D. Creates a cavity that damages tissue beyond its path
    Show answer

    Answer: D. Creates a cavity that damages tissue beyond its path

    Cavitation and pressure waves inside the closed skull damage tissue well beyond the bullet's track and raise ICP abruptly. Reasoning that damage is limited to a narrow track underestimates the injury.

19. Three weeks after a concussion, a 20-year-old reports persistent headache, poor concentration, irritability, and trouble sleeping. This is most consistent with:

    1. A. Second impact syndrome
    2. B. Chronic epidural hematoma
    3. C. Acute subdural hematoma
    4. D. Postconcussive syndrome
    Show answer

    Answer: D. Postconcussive syndrome

    Postconcussive symptoms such as headache, poor concentration, and mood changes can last weeks to months after even a mild TBI. Second impact syndrome is a sudden, catastrophic swelling with a new impact.

20. Second impact syndrome is a rare but often fatal condition in which:

    1. A. A second blow causes a depressed skull fracture at the same site
    2. B. A second blow before recovery causes rapid brain swelling
    3. C. A delayed hematoma develops a week after the injury
    4. D. The patient forgets a second blow to the same area
    Show answer

    Answer: B. A second blow before recovery causes rapid brain swelling

    When a brain that has not recovered from a concussion takes another hit, it can lose autoregulation and swell rapidly. This risk in young athletes is the reason for no same-day return to play.

21. A 28-year-old was punched and fell, striking his head on the curb. He is now alert with a GCS of 15 but has vomited twice and has a worsening headache. The best interpretation is that:

    1. A. A GCS of 15 rules out a significant brain injury
    2. B. Vomiting after a blow to the head is expected
    3. C. He needs CT evaluation despite the normal GCS
    4. D. He can stay home if a friend can watch him
    Show answer

    Answer: C. He needs CT evaluation despite the normal GCS

    Repeated vomiting (two or more episodes) is a high-risk feature for intracranial injury in decision rules such as the Canadian CT Head Rule, and a worsening headache adds concern; a GCS of 15 does not exclude an expanding bleed, so he needs transport for CT. A normal GCS early after injury is common in patients who later deteriorate. Vomiting is a warning sign, not an expected finding, once it repeats. Home observation is appropriate only after a patient with no high-risk features has been evaluated, not as a substitute for imaging.

22. A 4-month-old is brought in for vomiting and irritability. The caregiver's story keeps changing, and the infant has bruises on both upper arms. You should suspect:

    1. A. Abusive head trauma with subdural bleeding
    2. B. Viral gastroenteritis with dehydration
    3. C. A congenital skull defect from birth
    4. D. Bacterial meningitis spread from an ear infection
    Show answer

    Answer: A. Abusive head trauma with subdural bleeding

    Violent shaking tears bridging veins and causes subdural hematomas, often with retinal hemorrhages and few external marks; vomiting and irritability are common presenting complaints. A 4-month-old cannot crawl or cruise, so bruises plus a changing history point to abuse, which must be reported. Gastroenteritis explains vomiting but not patterned bruising or an inconsistent story. A congenital skull defect would not cause new bruising or a changing history. Meningitis can cause vomiting and irritability, but nothing here (no fever, no ear symptoms) suggests it, and it does not explain the bruises.

23. Cerebral contusions most commonly occur in the:

    1. A. Occipital lobe and cerebellum
    2. B. Frontal and temporal lobes
    3. C. Brainstem and medulla
    4. D. Thalamus and basal ganglia
    Show answer

    Answer: B. Frontal and temporal lobes

    The frontal and temporal poles rest against the rough anterior and middle cranial fossae and are bruised as the brain slides. The occipital lobe lies against a smoother surface.

24. In the first hours after a cerebral contusion, the patient's condition may worsen mainly because:

    1. A. The bruised tissue begins to heal and contract
    2. B. CSF production stops and the ventricles shrink
    3. C. Edema and bleeding around the contusion increase
    4. D. The skull expands to accommodate the swelling
    Show answer

    Answer: C. Edema and bleeding around the contusion increase

    Contusions often blossom, with surrounding edema and new bleeding raising ICP over hours to days. That delayed rise is why these patients need serial neurologic exams during transport.

25. A 22-year-old was struck on the temple, briefly lost consciousness, and is now drowsy with a GCS of 12 that is falling. A small community hospital without neurosurgery is 5 minutes away; a level I trauma center is 20 minutes away. His airway is open. You should transport to the:

    1. A. Level I trauma center with neurosurgery
    2. B. Community hospital because it is closer
    3. C. Nearest hospital, then request a transfer
    4. D. Trauma center only if a pupil dilates
    Show answer

    Answer: A. Level I trauma center with neurosurgery

    A temporal blow with brief loss of consciousness and a falling GCS suggests an expanding epidural hematoma, which is treated by prompt surgical evacuation; going directly to a center with neurosurgery avoids the delay of a secondary transfer. Field triage guidance sends patients with deteriorating mental status to the highest-level trauma center when the airway can be managed en route. Choosing the community hospital only because it is closer, or planning to transfer from there, puts an interfacility transfer between this patient and surgery; the closest hospital is the choice only when the patient is in extremis and the airway cannot be maintained. Waiting for a dilated pupil means waiting for herniation, a late sign.