5

Biophysical Mechanisms of Traumatic Brain

Injuries
Lee Ann Young, BS, MA1 Gregory T. Rule, MS2 Robert T. Bocchieri, PhD3 Jennie M. Burns, PhD2

1 Physical Security and Applied Sciences Sector, Applied Research Address for correspondence Lee Ann Young, BS, MA, Physical Security
Associates Inc., Dallas, Texas and Applied Sciences Sector, Applied Research Associates Inc, 13915
2 Physical Security and Applied Sciences Sector, Applied Research Preston Valley Pl, Dallas, TX 75240 (e-mail: [email protected]).
Associates, Inc., San Antonio, Texas
3 Silicon Valley Office, Applied Research Associates, Inc., Los Altos,
California

Semin Neurol 2015;35:5–11.

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Abstract Despite years of effort to prevent traumatic brain injuries (TBIs), the occurrence of TBI in
the United States alone has reached epidemic proportions. When an external force is
applied to the head, it is converted into stresses that must be absorbed into the brain or
redirected by a helmet or other protective equipment. Complex interactions of the
head, neck, and jaw kinematics result in strains in the brain. Even relatively mild
mechanical trauma to these tissues can initiate a neurochemical cascade that leads to
TBI. Civilians and warfighters can experience head injuries in both combat and
Keywords noncombat situations from a variety of threats, including ballistic and blunt impact,
► traumatic brain injury acceleration, and blast. It is critical to understand the physics created by these threats to
► blunt trauma develop meaningful improvements to clinical care, injury prevention, and mitigation.
► blast Here the authors review the current state of understanding of the complex loading
► ballistic conditions that lead to TBI and characterize how these loads are transmitted through
► physics soft tissue, the skull and into the brain, resulting in TBI. In addition, gaps in knowledge
► acceleration and injury thresholds are reviewed, as these must be addressed to better design
► diffuse axonal injury strategies that reduce TBI incidence and severity.

The occurrence of traumatic brain injury (TBI) in the United between the insult and the head, and discuss a summary of
States has reached epidemic proportions. The Center of the state of the science with respect to injury thresholds.
Disease Control (CDC) reports that there are 2.2 million
TBIs each year in the United States, including 50,000 fatalities
Causes of Traumatic Brain Injury
and 280,000 hospitalizations. Traumatic brain injury ac-
counts for 30% of injuries resulting in death in the United Traumatic brain injury is caused by a blunt, penetrating, or
States.1 Within the military, TBI statistics vary widely due to blast impact to the head. Key mechanisms by which energy
the difficulties associated with diagnosing mild TBI2; howev- may mechanically transfer into the skull and brain from
er, reports indicate that up to 20% of returning veterans from external sources include direct impact by a solid object (blunt
Afghanistan and Iraq have head injuries.3 Although many or penetrating impact) or fluid shock wave (blast impact), and
individuals recover function in the months following TBI, rapid linear and/or rotational acceleration of the head, result-
others continue to experience chronic symptoms of cognitive, ing in material stresses and strains. The direct impact of the
emotional, and physical impairment for months or years.4,5 head with a solid object may result in either a blunt or
Here we review the specific biophysical mechanisms of TBI penetrating injury, with the type of injury dependent upon
associated with blunt, penetrating, and blast impact to the the mass, speed, and cross-sectional area of the object in
head. For each, we describe the physics of the interaction comparison to the head.

Issue Theme Traumatic Brain Injury; Copyright © 2015 by Thieme Medical DOI http://dx.doi.org/
Guest Editor, Geoffrey Ling, MD, PhD, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1544242.
FAAN, FANA New York, NY 10001, USA. ISSN 0271-8235.
Tel: +1(212) 584-4662.
6 Biophysical Mechanisms of Traumatic Brain Injuries Young et al.

Blunt Impact low cross-sectional area, or low-velocity knives and compa-

Blunt-impact head wounds are caused by objects that are rably higher mass and lower cross-sectional area. Penetrating
usually of low velocity, high mass, and high cross-sectional objects of low velocity will cause lacerations on the scalp,
area. Blunt impact to the head may cause lacerations and fractures of the skull, and destruction or injury to the brain
contusions on the scalp, localized deformation of the skull, tissue in the immediate path of the penetrating object.
coup/contrecoup impact (impact of the brain with the inner For penetrating objects of sufficiently high velocity, there
walls of the skull) caused by the rapid linear and/or rotational is an additional risk of increased ICP from a temporary cavity
acceleration/deacceleration of the head, and increased intra- formed around the penetrating object. These high ICPs within
cranial pressure (ICP) gradients.6 The deformation of the skull the confines of the skull may cause the respiratory and cardiac
transmits localized stress to the underlying tissues resulting centers of the medulla to fail, resulting in immediate death.16
in strains to the neural and neurovascular tissue. The rebound For knife wounds or gunshot wounds, where most of the
of the skull from deformation can cause a separation in the energy of the object is expended during penetration of the
dura mater and skull, resulting in epidural hematomas.7 skull, there may only be localized damage and the patient may
Contusions are often found at the coup and contrecoup sites remain conscious. If the projectile or fragments of the skull

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
of impact. Intracranial pressure gradients are generated by remains inside the cranial cavity, these patients could be good
the inertia of the brain during head motion; when the brain candidates for débridement and survival is possible. If there is
lags behind the skull during linear acceleration, it “pushes” no penetration, but a fracture of the skull occurs, the patient
against the skull causing a pressure increase at the point of may remain conscious, but could still be in danger of a
loading and a pressure decrease (negative pressure) distally subsequent increase in ICP from an epidural, subdural, and
to that point.7 Axons are stretched as a result of the shear or subarachnoid hematoma.18,19
stresses and strains caused by the gross motion of the brain
inside the skull and these ICP gradients, leading to diffuse Blast Impact
axonal injuries (DAIs) characterized by an enlargement of the The environment in and around a blast is complex. For an
axons at the locations where the microtubules are damaged.8 exhaustive overview of blast physics, including shock and
Rapid linear or rotational acceleration of the head may blast wave generation, Mach stem formation, and the physics
alone, without the impact of the head with a foreign object, of explosions, there are numerous sources that provide
cause coup/contrecoup injury. There are two theories regard- thorough descriptions.20,21 Individuals exposed to blast
ing how rapid head acceleration results in brain injury. The may be exposed to multiple, concurrent effects of blast
first theory proposes that the brain is unable to rotate within such as thermal heating, ballistic impact from shrapnel and
the skull at the same velocity as the surrounding skull, leading fragments, blunt impact, and acceleration from falling or
to focal shear stresses and strains.6 Because the skull is most striking walls and large displaced masses, and impact with
constraining in the frontal compartments and around the fluid shock waves (blast overpressure) and acoustic waves,
foramen magnum, this theory predicts a concentration of and in nuclear explosions, radiation. Exposure to blast over-
injuries near these locations, and in fact literature shows that pressure alone can result in primary TBI caused by the direct
there is a predominance of anterior fossa injuries regardless impact of the shock against the head, direct transmission of
of whether the impact is frontal or occipital.9 The second blast wave energy through the head into the brain, and short
theory proposes that diffuse shearing of brain tissues occurs duration accelerative motions of the head caused by temporal
at sites where adjacent tissues have sufficiently different gradients in overpressure around the surface of the head.
densities to result in different rates of motion.10 Research Like any potentially injurious loading environment, blast
into the diffuse injuries caused by rotation show that the exposure establishes a transfer of energy from the external
damaging strains through inertial loading are greatest near environment into the head. This transfer of energy ultimately
the surface of the brain and decrease toward the center,11 results in tissue damage through several proposed underlying
such that low levels of rotational inertial loading affect only mechanisms, most of which have only limited validation in
the cortex, and only the more severe loads result in damage experimental data. These mechanisms include, but are not
down into the diencephalon.6 limited to, formation of air emboli or surges of fluid in the
Animal models and numerical models have shown that brain induced by thoracic pressure,22–24 shear and stress
DAI, acute subdural hematoma, and most other types of brain waves inducing micro (cellular and subcellular)25 and macro
injury can be generated purely by rotational motion.12–15 (gross morphological) level damage,26 physical deformation
However, more recently, the dominant consensus is that or flexing of the skull caused by pressure gradients,27 cere-
brain injuries result from a combination of translational brospinal fluid cavitation,28–30 and acceleration of the brain
motion, leading to direct site contusions and ICP, and rota- against the inside of the skull.31
tional motion, leading to shear strains.16 Coup and contre- To understand how blast waves may cause TBI, a funda-
coup injuries appear to be pressure induced, and brainstem mental understanding of how energy is deposited in the brain
injuries appear to be associated with shear strain.17 is required. The profile of the blast wave (e.g., number,
magnitude, and duration of the blast overpressure peaks) is
Penetrating Impact dependent on the characteristics of the explosive materials
Penetrating head wounds are caused by high-velocity objects, (e.g., dynamite [TNT] vs. improvised explosive device [IEDs]),
such as bullets or fragments, combined with low mass and the material in which the explosive is housed (e.g., metal

Seminars in Neurology Vol. 35 No. 1/2015

 Biophysical Mechanisms of Traumatic Brain Injuries Young et al. 7

casing, air, or soil), the presence of reflecting objects near the contrecoup regions are shown to be more exposed to high
exposed individual, the position and orientation of the indi- magnitude pressures, and consequently greater injury, due to
vidual to the blast, the stature and shape of the individual the reflection of the shock wave at the interface of the brain
resulting in varying exposed cross-sectional areas of the body, with the skull.42
and the use of protective equipment (e.g., Kevlar vests,
helmets, etc.).32,33 Thus, each blast scenario can result in
Thresholds of TBI
the exposure of an individual to a unique pressure wave
profile and a unique deposition of energy into the brain Blunt Impact and Acceleration
resulting in a unique injury. As seen in ►Fig. 1, pressures The most commonly used criterion for ascertaining whether the
across the head and body can vary widely. The pressure head will sustain an injury caused by blunt impact or accelera-
variations determine how energy affects the body in terms tion is the Head Injury Criterion (HIC).43 The HIC was proposed in
of implied forces, which can induce accelerations even with- 1970 based on the experimental results of 23 drop tests using
out direct impact. In this scenario, the soldier experienced five embalmed cadaver heads conducted in the late 1950s.44 The
extremely high pressures on the shoulder and arm, which equation to calculate the HIC is shown in Equation 1:

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
may have minimal physiological effect; however, exposures
to the left ear exceeded 8 psi, which is sufficient to rupture the
tympanic membrane.34 At higher pressure levels, from a
larger blast or a smaller standoff distance, the pressure where t1 is the initial time (s), t2 is the final time (s), and a(t) is
differentials across the head could cause both head deforma- the acceleration (g) at the center of gravity of the head. The
tion27 and acceleration.35 acceleration window (t2–t1) is usually 15 milliseconds (ms) or
Ultimately, exposure to blast results in neuronal damage 36 ms, depending upon the context of the impact (for
and tissue disruption, often detected in the traditional coup automotive applications, it is usually 15 ms). This criterion
and contrecoup regions, and diffuse axonal injuries caused by is primarily used to design protective measures for automo-
induced stress and strains within the living tissues of the biles. The Federal Motor Vehicle Safety Standard (FMVSS) 208
brain.36 Because these stresses and strains cannot be directly (occupant crash protection) and FMVSS-213 (child restraint
measured, measurement of ICP can provide a useful surrogate systems) use a HIC of 1,000 as the threshold for head injury
method for estimating energy deposition, particularly be- characterized by skull fracture or subdural hematomas. A
cause ICPs have shown to correlate with fatality rates.37 In head-injury risk curve was developed by Prasad and Mertz45
addition, computational modeling can provide significant using postmortem human subjects to determine the relation-
insight into transmission and dissipation of blast energy ship between the HIC and the probability of sustaining a life-
through and into the brain tissue. Several computational threatening injury. Based upon their data, a HIC of 1,400 gives
models validated against both live and cadaver animal tests a probability of sustaining a life-threatening brain injury of
have shown that the skull generally behaves as a low-pass 0.5 and a HIC of 1,000 puts the probability at 0.18.46 The other
filter by which the higher frequencies are removed as the injury criterion commonly used is the 150-g peak accelera-
blast wave passes through the calvarium.38–41 Based upon tion criterion. This criterion was based upon accident data
these simulations, stress waves induce shear, spallation, from U.S. Army aviation accidents,47,48 and developed from
implosion, and inertial effects within the brain tissue.33 experiments with the International Standards Organization
Computational models have also shown that peak stresses (ISO) head form; like the HIC, following this criterion in the
and strains within the brain correlate with high-pressure design of protective equipment can prevent skull fracture and
regions at the coup and contrecoup locations30,36; the coup/ subdural hematoma.

Fig. 1 Computational simulation of the exposure of a soldier to blast showing the profile of the peak overpressures across the surface of the entire
body. (Wiri S, Needham C. Reconstruction of IED blast loading to personnel in the open. Paper presented at: 21st International Shock Interaction
Symposium, International Shock Wave Institute; August 3–8, 2014; Riga, Latvia).

Seminars in Neurology Vol. 35 No. 1/2015

8 Biophysical Mechanisms of Traumatic Brain Injuries Young et al.

Penetrating Impact Discussion

Setting a single injury threshold for penetration injury is
challenging due to the interrelationship between the ve- Because experiments to investigate the threshold of TBI
locity, mass, shape, and diameter of the projectile. The using live humans are unethical, research approaches to
majority of the studies investigating trauma to all regions studying TBI have been limited to prospective or retrospec-
of the body use gelatin as the simulant for injury/wound tive studies on people who are likely to develop TBI (e.g.,
quantification. 49 For studies investigating penetrating in- athletes or veterans returning from war) or have been
jury to the head, projectiles are fired into a rectangular- diagnosed with TBI (e.g., survivors of automobile collisions
shaped simulant without any backing material to approxi- or terrorist attacks), or experimental testing on cadavers
mate the skull, which is an inappropriate means to study and animals. Accurate information regarding the bio-
the biomechanics of TBI. One study conducted by Yoganan- mechanical insult is difficult to obtain in most prospective
dan poured silicone dielectric gel (Sylgard 527; Dow Corn- studies and virtually all retrospective studies. The validity
ing, Midland, MI) and ballistic gelatin into a sphere that of cadaver tests is limited by the lack of muscle activation
approximated the skull. 50 The study used two different and physiological responses, and the validity of animal tests

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
projectiles (9 mm and 25 caliber) to determine the forma- is limited by the anatomical and functional differences of
tion and collapse of the temporary cavity inside the sphere the brain between species. Given these limitations, injury
and the pressures generated. Because the Sylgard gel has criteria and thresholds are based on indirect measures and
material properties closer to that of the human brain, global rigid-body kinematics. As a result, we have a limited
Yoganandan claimed the gel was a more appropriate sim- understanding of the specific biomechanical processes that
ulant for the study of penetrating brain injuries. Pressure lead to TBI.
distributions from experimental studies such as these can The criteria used to define the threshold for injury
be used to validate future models for determining brain caused by blunt impact to the head, the HIC and the 150-
injury thresholds. Although no single injury threshold for g criteria, are sufficient for evaluating helmets in protection
the head exists, it is widely believed that any skull pene- against skull fracture and hematoma; however, there are no
tration from a high-velocity projectile is likely to cause criteria for the other types of brain injuries (e.g., cognitive
instantaneous physiological incapacitation with a high dysfunction caused by neurochemical cascades) that can
likelihood of long-term disability or death.51 For this occur from blunt impact or rapid acceleration. Intense
reason, all ballistic head protection is designed to a zero- research into football-related impacts has attempted to
penetration criterion, leaving behind-armor blunt trauma correlate external accelerations with internal brain stresses
as the major risk of injury from ballistic threats because using computer simulations,31,55–57 head surrogates, and
ballistic helmets are allowed to deform. The NIJ (National real-time collection of acceleration data. Ongoing data
Institute of Justice) standard for ballistic helmets requires collections with collegiate football teams 58 and upcoming
that backface deformation be no more than 16 mm for joint Department of Defense and National Football League
crown left and right impacts and no more than 25.4 mm data collection efforts provide opportunities to collect
for front and rear impacts, but there is no scientific basis to massive amounts of data that have the potential to provide
link these values to brain injury.52 valuable insights into the threshold loads. However, both of
these efforts are impeded by ambiguity in the definition
Blast Impact and diagnosis of mild TBI, which makes it difficult to
There are no established injury criteria for blast-induced correlate measures of loads (pressures, forces, or impulses)
brain injury. Several efforts have been focused on develop- in these databases to consistent levels of injury, particularly
ing criteria for brain injury using a variety of outcomes when the susceptibility of the brain to injury changes with
ranging from apnea37 to fatality.39 Recently, computational repeated impacts.59 Additionally, these studies are chal-
modeling, validated against available test data, has provid- lenged by the lack of subjects who are naïve to concussion,
ed a first estimate for blast-induced brain injury criteria presenting a confounding factor of potential induced
based on the occurrence of apnea immediately following vulnerability.60
blast exposure.53 The primary challenge with respect to blast-induced TBI
In addition, the 150-g peak acceleration criterion and the is the remaining uncertainty regarding injury mechanisms.
HIC are the only criteria available to estimate the risk of head Although many mechanisms have been proposed, incon-
injury from accelerative motion. Unfortunately, these criteria sistencies in test methods, including exposure levels, ap-
only apply to gross accelerative motion in excess of 15 ms in proaches to blast generation and measures of effect, have
duration; both modeling and testing has demonstrated that resulted in confusing and sometimes conflicting results.
blast exposures of 30 to 40 psi peak overpressure can induce One of the most significant experimental issues has been
short duration, from < 1 to 6 to 7 ms, accelerations in excess replication of blast environments in a laboratory setting.
of 400 g.54 Furthermore, criteria based on data from tradi- Shock tubes have proliferated in the last decade of blast
tional blunt impact tests are likely not applicable to the blast neurotrauma research; however, many tubes are used
impact as the mechanics involved are different, thus render- incorrectly, placing the test specimen downstream of the
ing conclusions based upon these criteria for blast-induced shock tube exit (i.e., in front of the tube), rather than inside
neurotrauma highly questionable. it. Because the shock wave rapidly expands outside the tube

Seminars in Neurology Vol. 35 No. 1/2015

 Biophysical Mechanisms of Traumatic Brain Injuries Young et al. 9

and is followed by a jetting of cold air, a test specimen References

placed at this location is exposed to a significant dynamic 1 Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the

pressure resulting in large head accelerations.61 An over- United States emergency department visits, hospitalizations, and
deaths. Atlanta, GA: Centers for Disease Control and Prevention,
pressure measurement outside the shock tube, translated
National Center for Injury Prevention and Control; 2010
to dynamic pressure using Rankine-Hugoniot relations, will 2 Levine B, Schweizer TA, O’Connor C, et al. Rehabilitation of execu-
lead to incorrect values of overpressure—the calculated tive functioning in patients with frontal lobe brain damage with
dynamic pressure could be significantly lower than actual goal management training. Front Hum Neurosci 2011;5:9
overpressure downstream of the shock tube. Test data 3 Theeler BJ, Flynn FG, Erickson JC. Headaches after concussion in US
collected this way are often published as demonstrating soldiers returning from Iraq or Afghanistan. Headache 2010;50(8):
1262–1272
the effects of blast overpressure on the brain, when the
4 Kraus JF, McArthur DL, Silberman TA. Epidemiology of mild brain
dominant effect was actually head acceleration due to injury. Semin Neurol 1994;14(1):1–7
dynamic pressure. The impact of this error can be signifi- 5 Kraus JF, Nourjah P. The epidemiology of mild, uncomplicated
cant. In blast tube experiments where a specific effort was brain injury. J Trauma 1988;28(12):1637–1643
made to prevent the accelerative motion of the head, the 6 Post A, Hoshizaki TB. Mechanisms of brain impact injuries and

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
acceleration of porcine heads placed just outside the tube their prediction: a review. J Trauma 2012;14(4):327–349
7 Gurdjian ES. Re-evaluation of the biomechanics of blunt impact
opening was, never the less, measured in excess of 1200 g
injury of the head. Surg Gynecol Obstet 1975;140(6):
and neurotrauma was observed.41 In contrast, ongoing 845–850
tests led by one of the authors on porcine subjects placed 8 King AI. Fundamentals of impact biomechanics: Part I—biome-
fully inside the shock tube resulted in negligible head chanics of the head, neck, and thorax. Annu Rev Biomed Eng 2000;
accelerations. Even with more than double the peak over- 2:55–81
9 Hardy WN, Khalil TB, King AI. Literature review of head injury
pressure, the tests yielded little evidence of neurologic
biomechanics. Int J Impact 1994;15(4):561–586
trauma using advanced imaging methods and postmortem
10 Ommaya AK, Gennarelli TA. Cerebral concussion and traumatic
histology. unconsciousness. Correlation of experimental and clinical obser-
Another issue with blast-induced TBI research is deter- vations of blunt head injuries. Brain 1974;97(4):633–654
mining a correct method to scale the results from animal 11 Ommaya AK, Thibault L, Bandak FA. Mechanisms of impact head
models to humans. For pulmonary injuries, body mass has injury. Int J Impact 1994;15(4):535–560
12 Adams JH, Graham DI, Gennarelli TA. Acceleration induced head
been used for decades to scale data from smaller and larger
injury in the monkey. II. Neuropathology. Acta Neuropathol Suppl
animals and to a human.62 For brain injuries, it is not yet clear 1981;7:26–28
whether this body mass scaling is appropriate, or whether 13 Adams JH, Graham DI, Gennarelli TA. Head injury in man and
blast overpressures and impulses should be scaled by head experimental animals: neuropathology. Acta Neurochir Suppl
mass, brain mass, skull thickness, or other physical proper- (Wien) 1983;32:15–30
ties.61,63 In fact, proper scaling requires an understanding of 14 Gennarelli TA, Abel JM, Adams H, et al. Differential tolerance of
frontal and temporal lobes to contusion induced by angular
the underlying mechanism of injury. In the absence of a clear
acceleration. In: Proceedings of the 23rd Stapp Car Crash Confer-
understanding of the injury mechanism, we cannot deter- ence. SAE paper 791022.Warrendale, PA; Society of Automotive
mine the appropriate scaling methods, and in the absence of Engineers; 1979
appropriate scaling methods, we cannot confidently estimate 15 Zhang L, Yang KH, Dwarampudi R, et al. Recent advances in brain
human injury thresholds using the data collected with animal injury research: a new human head model development and
validation. Stapp Car Crash J 2001;45:369–394
models.
16 Gurdjian ES. Head injury from antiquity to the present with special
reference to penetrating head wounds. Springfield, IL: Charles C.
Conclusion Thomas Publishing; 1973
17 Zhou C, Khalil TB, King AI. A new model for comparing responses of
Research to determine the dose–response curves or thresh- the homogeneous and inhomogeneous human brain. In: Proceed-
olds of TBI remain important in developing safer protective ings of the 39th Stapp Car Crash Conference. Warrendale, PA;
Society of Automotive Engineers; 1995:121–136
equipment and minimizing the risk of neurotrauma for both
18 Gorske T. Traumatic brain injury basics and beyond. Paper
the civilian and military communities. For ballistic and pene- presented at: Pennsylvania Psychological Association Annual
trating impact neurotrauma, physiological-based behind- Convention; June 18–21, 2014; Harrisburg, PA
helmet blunt trauma criteria are needed. For blunt impact 19 Raymond DE, Crawford GS, Van Ee C, Bir CA. Biomechanics of
neurotrauma, criteria are needed for mild and moderate temporo-parietal skull fracture from blunt ballistic impact. Paper
closed-head injuries, such as rapid linear or rotational accel- presented at: The ASME Summer Bioengineering Conference;
June 25–29, 2008; Marco Island, FL
eration, that do not involve skull fractures or subdural hema-
20 Needham CE. Blast Waves (Shock Wave and High Pressure
tomas. For blast and to a lesser extent, blunt impact-caused Phenomena). Heidelberg, Germany: Springer; 2010
neurotrauma, the greatest need continues to be clarity on the 21 U.S. National Academies of Science Committee on Gulf War and
mechanisms of injury so that we can develop valid injury Health: Brain Injury in Veterans and Long Term Health Outcomes.
criteria in animal models and scale those criteria to humans. Military personnel with traumatic brain injury at risk for serious long-
term health problems; more studies needed on health effects of blast
Investigation into the mechanisms of TBI will ultimately
injuries. December, 4 2008. Available at: http://www8.nationalaca-
improve our ability to prevent, diagnose, and treat this
demies.org/onpinews/newsitem.aspx?RecordID¼12436. Accessed
debilitating disease. May 15, 2010

Seminars in Neurology Vol. 35 No. 1/2015

10 Biophysical Mechanisms of Traumatic Brain Injuries Young et al.

22 Cernak I, Savic J, Malicevic Z, et al. Involvement of the central 42 Zhu F, Skelton P, Chou CC, Mao H, Yang KH, King AI. Biomechanical
nervous system in the general response to pulmonary blast injury. responses of a pig head under blast loading: a computational
J Trauma 1996;40(3, Suppl): S100–S104 simulation. Int J Numer Methods Biomed Eng 2013;29(3):
23 Lemonick D. Bombings and blast injuries: a primer for physicians. 392–407
Am J Chin Med 2011;8(3):134–140 43 Versace J. A review of the severity index. In: Proceedings of the
24 Courtney AC, Courtney MW. A thoracic mechanism of mild 15th Stapp Car Crash Conference. SAE Paper 710881. Warrendale,
traumatic brain injury due to blast pressure waves. Med Hypoth- PA; Society of Automotive Engineers; 1971
eses 2009;72(1):76–83 44 Lissner HR, Lebow M, Evans FG. Experimental studies on the
25 Chen Y, Huang W. Non-impact, blast-induced mild TBI and PTSD: relation between acceleration and intracranial pressure changes
concepts and caveats. Brain Inj 2011;25(7-8):641–650 in man. Surg Gynecol Obstet 1960;111:329–338
26 Chafi MS, Karami G, Ziejewski M. Biomechanical assessment of 45 Prasad P, Mertz H. The position of the United States delegation to
brain dynamic responses due to blast pressure waves. Ann Biomed the ISO Working Group 6b on the use of HIC in the automotive
Eng 2010;38(2):490–504 environment. SAE Paper 821246. Warrendale, PA; Society of
27 Moss WC, King MJ, Blackman EG. Skull flexure from blast waves: a Automotive Engineers; 1982
mechanism for brain injury with implications for helmet design. 46 Hutchinson J, Kaiser MJ, Lankarani HM. The head injury criterion
Phys Rev Lett 2009;103(10):108702 (HIC) functional. Appl Math Comput 1998;96(1):1–16

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
28 Goeller J, Wardlaw A, Treichler D, Weiss G. Cavitation as a possible 47 Slobonik BA. SPH-4 helmet damage and head injury correlation.
damage mechanism for traumatic brain injury (TBI) from an USAARL-80–7. Fort Rucker, AL: US Army Aeromedical Research
improvised explosive device (IED) blast. DARPA SBIR Final Report. Laboratory; 1980
Arlington, VA: Defense Advanced Research Projects Agency 48 McIntire BJ, Whitley P. Blunt impact performance characteristics of
(DARPA); 2013 the advanced combat helmet and the paratrooper and infantry
29 Taylor PA, Ford CC. Simulation of blast-induced early-time intra- personnel armor system for ground troops helmet. USAARL Report
cranial wave physics leading to traumatic brain injury. J Biomech No. 2005–12. Fort Rucker, AL: US Army Aeromedical Research
Eng 2009;131(6):061007 Laboratory; 2005
30 Taylor PA, Ludwigsen JS, Ford CC. Investigation of blast-induced 49 Yoganandan N, Pintar FA, Kumaresan S, Maiman DJ, Hargarten SW.
traumatic brain injury. Brain Inj 2014;28(7):879–895 Dynamic analysis of penetrating trauma. J Trauma 1997;42(2):
31 Zhang L, Yang KH, King AI. A proposed injury threshold for 266–272
mild traumatic brain injury. J Biomech Eng 2004;126(2): 50 Yoganandan N, Pintar FA, Zhang J, Gennarilli TA. Biomechanical
226–236 aspects of blunt and penetrating head injuries. In: Gilchrist MD,
32 Nyein M, Jerusalem A, Radovitzky R, Moore D, Noels L. Modeling ed. IUTAM Symposium on Impact Biomechanics: From Fundamen-
blast related brain injury. Paper presented at: The 26th Army tal Insights to Applications. Heidelberg, GermanySpringer2005:
Science Conference; December 1–4, 2008; Orlando, FL. Available 173–184
at: http://handle.dtic.mil/100.2/ADA504193. Accessed June 12, 51 MacPherson D. Bullet Penetration: Modeling the Dynamics and
2010 Incapacitation Resulting from Wound Trauma. El Segundo, CA:
33 Elder GA, Mitsis EM, Ahlers ST, Cristian A. Blast-induced mild Ballistic Publications; 2005
traumatic brain injury. Psychiatr Clin North Am 2010;33(4): 52 Committee on Review of Test Protocols Used by the DoD to Test
757–781 Combat Helmets. Board on Army Science and Technology; Division
34 Department of Energy. Manual for the Prediction of Blast and on Engineering and Physical Sciences; National Research Council
Fragment Loadings on Structures. DOE/TIC-11268. Amarillo, TX: Review of Department of Defense Test Protocols for Combat
Department of Energy, Amarillo Energy Office; 1980 Helmets. Test Protocols for Backface Deformation: Statistical
35 Przekwas A, Tan X, Rule G, Iyer K, Ott K, Merkle A. Modeling Considerations and Assessment. Washington, DC: National Acad-
articulated human body dynamics under a representative blast emies Press; 2014. Available at: http://www.nap.edu/openbook.
loading. Paper presented at: The ASME 2011 International Me- php?record_id¼18621&page¼R1. Accessed January 3, 2015
chanical Engineering Congress & Exposition; November 11–17, 53 Panzer MB, Wood GW, Bass CR. Scaling in neurotrauma: how do
2011; Denver, CO we apply animal experiments to people? Exp Neurol 2014;
36 Dagro A, McKee P, Kraft R, Zhang T, Satapathy S. A preliminary 261:120–126
investigation of traumatically induced axonal injury in a three- 54 Lockhart P, Cronin D, Williams K, Ouellet S. Investigation of head
dimensional (3-D) finite element model (FEM) of the human head response to blast loading. J Trauma 2011;70(2):E29–E36
during blast-loading. 2013. ARL-TR-6504 website. Available at: 55 King AI, Yang KH, Zhang L, et al. Is head injury caused by linear or
http://oai.dtic.mil/oai/oai? angular acceleration. Paper presented at: International Research
verb¼getRecord&metadataPrefix¼html&identifier¼ADA588181. Council on Biomechanics of Injury Conference; September 24–26,
Accessed January 3, 2015 2003; Lisbon, Portugal
37 Panzer MB, Bass CR. Human results from animal models: scaling 56 Duma SM, Manoogian SJ, Bussone WR, et al. Analysis of real-time
laws for blast neurotrauma. Paper presented at: National head accelerations in collegiate football players. Clin J Sport Med
Neurotrauma Society Annual Meeting; July 22–25, 2012; 2005;15(1):3–8
Phoenix, AZ 57 Pellman EJ, Viano DC, Tucker AM, Casson IR; Committee on Mild
38 Yu AW, Wang H, Matthews KA, Bass CR. Mouse lethality risk and Traumatic Brain Injury, National Football League. Concussion in
intracranial pressure during exposure to blast. Paper presented at: professional football: location and direction of helmet impacts-
The Biomedical Engineering Society Annual Meeting; October 24– Part 2. Neurosurgery 2003;53(6):1328–1340, discussion 1340–
27, 2012; Atlanta, GA 1341
39 Rafaels K, Bass CR, Salzar RS, et al. Survival risk assessment for 58 Greenwald RM, Gwin JT, Chu JJ, Crisco JJ. Head impact severity
primary blast exposures to the head. J Neurotrauma 2011;28(11): measures for evaluating mild traumatic brain injury risk exposure.
2319–2328 Neurosurgery 2008;62(4):789–798, discussion 798
40 Rafaels KA, Bass CR, Panzer MB, et al. Brain injury risk from 59 Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative
primary blast. J Trauma Acute Care Surg 2012;73(4):895–901 effects associated with recurrent concussion in collegiate foot-
41 Shridharani JK, Wood GW, Panzer MB, et al. Porcine head response ball players: the NCAA Concussion Study. JAMA 2003;290(19):
to blast. Front Neurol 2012;3:70 2549–2555

Seminars in Neurology Vol. 35 No. 1/2015

 Biophysical Mechanisms of Traumatic Brain Injuries Young et al. 11

60 Long J. Combined effects of primary and tertiary blast on rat brain: 62 Bowen IG, Fletcher ER, Richmond DR. Estimate of man’s tolerance
characterization of a model of blast-induced mild traumatic brain to the direct effects of air blast. Albuquerque, NM: Lovelace
injury. Contract No. W81XWH-11–2-0127. Tacoma, WA: Geneva Foundation for Medical Education and Research; 1968
Foundation; 2013 63 Wood G, Panzer M, Yu A, Rafaels K, Matthews K, Bass C. Scaling in
61 Needham CE, Ritzel D. Bad science yields wrong blast neurotrauma. Paper presented at: International Research
conclusion: blast testing issues and TBI. Front Neurology, in Council on Biomechanics of Injury Conference; September 11–13,
press 2013; Gothenburg, Sweden

This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Seminars in Neurology Vol. 35 No. 1/2015

Copyright of Seminars in Neurology is the property of Thieme Medical Publishing Inc. and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder's express written permission. However, users may print, download, or email
articles for individual use.