An 18-year-old man experienced a fall while intoxicated. He did not lose consciousness but became immediately disoriented with impaired orientation and ability to follow commands. He was lethargic and required ICU monitoring with frequent neuro checks, not regaining orientation to time until 4 days postinjury. He was able to transition back to his previous living situation but was notably more irritable. His alcohol use increased and he had difficulty verbalizing the potential consequences.

Brain MRI performed 2 days postinjury demonstrated a left orbital gyrus hemorrhagic contusion ( Fig. 63.1 ).

Frontal hemorrhagic contusion. Brain MRI, coronal T2, shows left orbital gyrus contusion with edema ( arrowhead ) and central hypointense blood products ( arrow ).

Alcohol intoxication or other recreational drugs, as well as prescription medications for pain or agitation, can contribute to altered consciousness after a fall.

Seizures, both early posttraumatic and withdrawal-related with postictal encephalopathy, can occur especially in the first 7 days following injury.

Peritraumatic hypoxic-ischemic injury can occur with a history of unresponsiveness, oxygen desaturation, or respiratory distress.

Clearing of confusion at less than 1 week distinguishes moderate from severe TBI.

Diffuse microhemorrhages can be seen in diffuse axonal injury (DAI), small vessel vasculopathies, and following radiation therapy.

Localized macro- and microhemorrhages may be seen in association with underlying vascular malformations or tumors.