Claire M. Spettell

Delayed and Progressive Brain Injury in Closed-Head Trauma

The importance of delayed or secondary brain insults in the eventual outcome of closed-head trauma has been documented in experimental models. To understand this phenomenon in the clinical setting, we studied a series of head-injured patients in whom multiple cranial computed tomographic (CT) scans were obtained. Patients whose follow-up CT studies revealed new intracranial lesions or worsening, compared with admission findings, were considered to have delayed cerebral injury. One hundred forty-nine (44.5%) of 337 consecutively studied patients developed delayed brain injury. There were highly significant associations (P < 0.001) between the appearance of delayed cerebral insults and the severity of the initial brain injury, the need for cardiopulmonary resuscitation in the field, the presence of coagulopathy at admission, and subdural hematoma on the initial CT scan. In addition, delayed injury was associated (P < 0.001) with higher mortality, slowed recovery, and poorer outcome at 6 months. Delayed brain injury was not significantly associated with patient age, sex, injury mechanism, associated injury, the need for endotracheal intubation in the field, early talking, CT abnormality other than intracranial hematoma, or type of residual neurological deficits. We used multiple regression analysis to explore the relationship between severity of injury, delayed insults, and outcome. As expected, the severity of the initial brain trauma contributed significantly to neurological outcome. The presence of delayed cerebral injury makes the outcome dramatically worse for each category of initial injury severity. The relationship between initial and secondary brain injury is discussed.

Delayed and progressive brain injury in children and adolescents with head trauma.

We performed serial CT scans on 351 children and adolescents with serious closed-head injury. Delayed or progressive lesions were encountered in 145 (41%). The occurrence of such delayed cerebral injuries correlated with the severity of the initial head trauma, with the presence of major extracranial injury and with studies of coagulopathy on admission. The presence of delayed cerebral injury had a profound influence on survival and recovery from head trauma, especially when the initial severity of the head injury was taken into account. We conclude that serial CT scans provide a reliable means of diagnosing and following the progress of delayed cerebral injury in the pediatric population.

Limitations of neurological assessment in mild head injury

The authors have investigated two commonly used methods of assessing neurological status in patients with mild head injury to determine whether they can predict intracranial damage. Of 686 such patients with cranial computed tomography (CT) scans, scan results were recorded, along with total and motor components of the Glasgow Coma Scale (GCS) and the Reaction Level Scale (RLS85). Despite relatively normal admission neurological examinations, 127 of the 689 patients (18.4%) had intracranial lesions, and 38 (5.5%) required surgery. There was no significant difference in distribution of the GCS in patients with and without intracranial lesions. The RLS85 was superior to the GCS in predicting intracranial pathology, and a significant association between RLS85 and lesions on CT scanning was noted. However, even this test was normal in 19 patients found to have intracranial pathology, including nine who required surgery. The authors conclude that a normal or near-normal mental status examination in a head-injured patient on arrival at the emergency room is inadequate to exclude a potentially serious intracranial lesion. It is unlikely that further refinements in the clinical evaluation will result in diagnostic accuracy comparable with that of CT scanning. Accordingly, we recommend that any patient who has suffered a loss of consciousness or amnesia following head injury have an urgent cranial CT scan.

Effects of intensity of treatment and length of stay on rehabilitation outcomes

The combined effects of intensity of treatment and length of stay during inpatient rehabilitation hospitalization on the outcomes of 95 traumatic brain injury patients were examined. Outcome was assessed using the Rancho Scale and three measures of functional status--physical performance, higher-level cognitive skills, and cognitively mediated physical skills. The effects of intensity of treatment and length of stay were assessed using 2 x 2 analyses of variance with repeated measures. The results showed clearly that both length of stay and intensity of treatment affect outcomes. Patients in the long length of stay group consistently made more progress across all outcome variables than patients in the short length of stay group. However, the greater progress of the long length of stay patients was from a point significantly more disabled than that of the short length of stay patients, with improvement at discharge to the point at which the groups were now equal. The effect of intensity of treatment was significant or closely approached significance for higher-level cognitive skills and Rancho Level. In the long length of stay group, the two intensity groups were initially equivalent, but at discharge the high-intensity group surpassed the low-intensity group. The practical implications of the results are discussed.

ABBREVIATED INJURY SCALING OF HEAD INJURY AS A PROGNOSTIC TOOL FOR FUNCTIONAL OUTCOME

The use of Abbreviated Injury Scaling for the head region (HAIS) was evaluated as a prognostic index of functional outcome in 503 consecutive patients with severe injury to the brain who survived initial resuscitation. Although a strong statistical relationship between HAIS and outcome as measured by the Glasgow Outcome Scale was demonstrated, its clinical usefulness is limited. HAIS may be most useful as a classifier for comparative studies of populations and for the evaluation of therapeutic modalities.