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I shouldn’t have to tell you that traumatic brain injury is a major cause of morbidity and mortality. I shouldn’t have to. But I will. And it is. In severe cases of head injury, there can be delayed and irreversible deterioration in the nervous system for which there is no treatment and the prognosis is grim. This week on the program, Dr. Monisha Kumar (University of Pennsylvania) discusses the worst of the worst of these scenarios, what to look out for, and expert recommendations on what to do when it happens. Produced by James E. Siegler and Monisha Kumar. Music courtesy of Rui, Swelling, Unheard Music Concepts, Jahzzar, Ian Southerland, and TRG Banks. The opening theme was composed by Jimothy Dalton. Sound effects by Mike Koenig and Daniel Simion. Unless otherwise mentioned in the podcast, no competing financial interests exist in the content of this episode. BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision making. Be sure to follow us on Twitter @brainwavesaudio for the latest updates to the podcast. REFERENCES Strich SJ. Diffuse degeneration of the cerebral white matter in severe dementia following head injury. Journal of neurology, neurosurgery, and psychiatry. 1956;19:163-85. Adams JH, Graham DI, Murray LS and Scott G. Diffuse axonal injury due to nonmissile head injury in humans: an analysis of 45 cases. Annals of neurology. 1982;12:557-63. Povlishock JT, Becker DP, Cheng CL and Vaughan GW. Axonal change in minor head injury. J Neuropathol Exp Neurol. 1983;42:225-42. Gentry LR. Imaging of closed head injury. Radiology. 1994;191:1-17. Meythaler JM, Peduzzi JD, Eleftheriou E and Novack TA. Current concepts: diffuse axonal injury-associated traumatic brain injury. Arch Phys Med Rehabil. 2001;82:1461-71. Arfanakis K, Haughton VM, Carew JD, Rogers BP, Dempsey RJ and Meyerand ME. Diffusion tensor MR imaging in diffuse axonal injury. AJNR American journal of neuroradiology. 2002;23:794-802. Scheid R, Preul C, Gruber O, Wiggins C and von Cramon DY. Diffuse axonal injury associated with chronic traumatic brain injury: evidence from T2*-weighted gradient-echo imaging at 3 T. AJNR American journal of neuroradiology. 2003;24:1049-56. DeKosky ST, Ikonomovic MD and Gandy S. Traumatic brain injury--football, warfare, and long-term effects. The New England journal of medicine. 2010;363:1293-6. Johnson VE, Stewart W and Smith DH. Widespread tau and amyloid-beta pathology many years after a single traumatic brain injury in humans. Brain Pathol. 2012;22:142-9. Schrag M and Greer DM. Clinical associations of cerebral microbleeds on magnetic resonance neuroimaging. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2014;23:2489-2497. Haghbayan H, Boutin A, Laflamme M, Lauzier F, Shemilt M, Moore L, Zarychanski R, Douville V, Fergusson D and Turgeon AF. The Prognostic Value of MRI in Moderate and Severe Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Critical care medicine. 2017;45:e1280-e1288. Izzy S, Mazwi NL, Martinez S, Spencer CA, Klein JP, Parikh G, Glenn MB, Greenberg SM, Greer DM, Wu O and Edlow BL. Revisiting Grade 3 Diffuse Axonal Injury: Not All Brainstem Microbleeds are Prognostically Equal. Neurocritical care. 2017;27:199-207. van Eijck MM, Schoonman GG, van der Naalt J, de Vries J and Roks G. Diffuse axonal injury after traumatic brain injury is a prognostic factor for functional outcome: a systematic review and meta-analysis. Brain Inj. 2018;32:395-402.