What are Changes in Pupils?

The pupils are the black circular openings in the center of the eyes that regulate the amount of light entering the eye. Changes in pupil size, shape, symmetry, or reaction to light can sometimes indicate serious neurological conditions.

After head trauma, unequal pupils or sluggish pupil reactions may suggest increased pressure inside the skull or injury to important brain structures.

Common Causes

• Head injury
• Brain hemorrhage
• Stroke
• Brain tumors
• Nerve damage
• Eye disorders
• Medication effects
• Migraine 

How is it Diagnosed?

Doctors evaluate:

• Pupil size
• Reaction to light
• Eye movements
• Neurological function
• Vision 

Investigations

• CT Brain
• MRI Brain
• Eye examination
• Neurological assessment
• Blood tests 

Treatment Options

Treatment focuses on correcting the underlying condition.

This may include:

• Emergency neurosurgical care
• Stroke treatment
• Management of eye disorders
• Medication adjustment 

When Should You Consult a Doctor?

Seek medical evaluation if pupil changes are new, persistent, or associated with neurological symptoms.

Red Flags

• Unequal pupils after head injury
• Loss of consciousness
• Severe headache
• Vision loss
• Weakness
• Confusion
• Seizures 

FAQs

Are unequal pupils always dangerous?

Not always, but sudden changes require medical evaluation.

Can head injuries affect pupil size?

Yes. Pupil abnormalities are important indicators of brain injury.

Is imaging necessary?

Often yes, especially following trauma.

When to Consult:

Changes in pupil appearance may indicate serious neurological conditions. Prompt medical evaluation is essential.

What is Drowsiness?

Drowsiness refers to excessive sleepiness, reduced alertness, and difficulty staying awake. Following a head injury, drowsiness may indicate concussion, brain swelling, or intracranial bleeding.

Common Causes

• Concussion
• Brain swelling
• Intracranial hemorrhage
• Medication effects
• Sleep deprivation
• Metabolic disorders 

How is it Diagnosed?

Doctors assess:

• Level of consciousness
• Responsiveness
• Neurological status
• Glasgow Coma Scale score 

Investigations

• CT Scan Head
• MRI Brain
• Blood tests
• Neurological examination 

Treatment Options

• Observation
• Hospital admission
• Treatment of underlying cause
• Emergency neurosurgical care when required 

When Should You Consult a Doctor?

Any increasing drowsiness after head injury should be evaluated urgently.

Red Flags

• Difficulty waking the patient
• Loss of consciousness
• Vomiting
• Seizures
• Confusion
• Weakness
• Unequal pupils 

FAQs

Is it normal to feel sleepy after a concussion?

Mild sleepiness can occur, but worsening drowsiness requires immediate assessment.

Can drowsiness indicate brain bleeding?

Yes. Excessive drowsiness can be a sign of intracranial hemorrhage.

Should someone with a head injury be monitored while sleeping?

Yes. Monitoring is often recommended after significant trauma.

When to Consult:

Excessive sleepiness after a head injury should never be ignored. Early neurological assessment can help identify serious complications and improve outcomes.

What are Raccoon Eyes?

Raccoon eyes (periorbital ecchymosis) refer to bilateral or unilateral dark bruising around the eyes following head trauma. The characteristic appearance results from blood tracking along fascial planes into the periorbital region, confined by the orbital septum. This clinical sign is most commonly associated with fractures of the anterior cranial fossa.

Importantly, raccoon eyes may not appear immediately — they typically develop 1–3 days after initial injury as blood continues to track along tissue planes. The presence of raccoon eyes, when bilateral and not caused by direct periorbital trauma, has strong predictive value for an underlying basilar skull fracture.

PRIMARY: Herbella FA, et al. 'Raccoon eyes' (periorbital haematoma) as a sign of skull base fracture. Injury. 2001;32(10):745–747. [PMID: 11754879]

SUPPORTING: Simon LV, Newton EJ. Basilar Skull Fractures. StatPearls [Updated Aug 2023]. PMID: 29489178

SUPPORTING: McPheeters RA, White S, Winter A. Raccoon eyes. West J Emerg Med. 2010;11(1):97. [PMC2850869]

SUPPORTING: Solai CA, et al. Clinical Signs of Basilar Skull Fracture and Their Predictive Value. J Trauma Nurs. 2018;25(5):301–306. [PMID: 30216260]

Common Causes

• Basilar skull fracture (anterior cranial fossa)
• Facial fractures with periorbital involvement
• Severe blunt head trauma
• Road traffic accidents
• Falls from height
• Sports injuries

Investigations

• CT Head (investigation of choice in acute settings)
• CT Facial Bones (if facial fracture suspected)
• MRI Brain (selected cases for soft-tissue detail)
• Neurological examination
• Skull base assessment

Plain skull X-rays are not sensitive for detecting basilar skull fractures. Multi-detector CT (MDCT) with thin-slice scanning is recommended when basilar fracture is clinically suspected.

Simon LV, Newton EJ. Basilar Skull Fractures. StatPearls [Updated Aug 2023]. PMID: 29489178