An overview of head injury: Its consequences and rehabilitation

This article provides a broad overview of the consequences of head injury and approaches to its rehabilitation. Of necessity, no specific area is covered in depth. Sufficient references are provided, however, for the reader who desires further information in any of the areas discussed. It is hoped that, by providing this broad overview, the reader will develop a generalized picture of head injury rehabilitation. Furthermore, the article is designed for 'novices' in the field of head injury rehabilitation such as (1) the family/significant others of the injured persons—so they may begin to know what to expect and to plan for appropriate services; (2) the rehabilitation student—so he or she may be introduced to this emerging specialization and thereby make more informed career choices; and (3) perhaps most important, the newly hired, novice head injury practitioner. This article could form the nucleus of an orientation or in-service training programme for new employees who are not sufficiently knowledgeable in this specialization. In-service programmes are often a necessity for new employees (even on the graduate level) because of the recent, large increase in the number of facilities and programmes specializing in head injury rehabilitation, and because of the lack of available head injury rehabilitation education and training programmes.     

The influence of hypoxia and hypotension on recovery from head injury

Of a group of 363 surviving patients admitted to hospital unconscious following head injury, 8.5 per cent were hypoxic, 15.1 per cent hypotensive, and 3.3 per cent both. The speed of recovery as indicated by the unconsciousness time, period of post-traumatic disorientation, and time in hospital was slower in those patients who were hypotensive, but the quality of recovery was not influenced. Hypoxia, on the other hand, did not affect the speed of recovery, but appeared significantly to reduce the chances of the patient returning to normal work. The few patients who were hypoxic and hypotensive showed the cumulative effect of both.     

The causes and consequences of minor head injury in the elderly

The majority of patients admitted to hospital after head injury are young men and the characteristics of this group tend to dominate accounts of cranial injury. All patients of 65 years or more admitted to the Edinburgh Royal Infirmary neurotrauma unit over a 1-year period were studied and 146 suffering minor head injury were identified. In this group the sex incidence was equal and falls were responsible for two-thirds of the injuries. Alcohol was a contributory factor in over half of the male patients. The incidence of other noteworthy medical and social factors was high and the length of stay in hospital was twice that of younger persons. It is suggested that the elderly represent a group with special needs which might most effectively be met by an overnight observation ward served by neurosurgeons and specialists in geriatric medicine.     

Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury.

OBJECT: Progressive intracranial hemorrhage after head injury is often observed on serial computerized tomography (CT) scans but its significance is uncertain. In this study, patients in whom two CT scans were obtained within 24 hours of injury were analyzed to determine the incidence, risk factors, and clinical significance of progressive hemorrhagic injury (PHI). METHODS: The diagnosis of PHI was determined by comparing the first and second CT scans and was categorized as epidural hematoma (EDH), subdural hematoma (SDH), intraparenchymal contusion or hematoma (IPCH), or subarachnoid hemorrhage (SAH). Potential risk factors, the daily mean intracranial pressure (ICP), and cerebral perfusion pressure were analyzed. In a cohort of 142 patients (mean age 34 +/- 14 years; median Glasgow Coma Scale score of 8, range 3-15; male/female ratio 4.3: 1), the mean time from injury to first CT scan was 2 +/- 1.6 hours and between first and second CT scans was 6.9 +/- 3.6 hours. A PHI was found in 42.3% of patients overall and in 48.6% of patients who underwent scanning within 2 hours of injury. Of the 60 patients with PHI, 87% underwent their first CT scan within 2 hours of injury and in only one with PHI was the first CT scan obtained more than 6 hours postinjury. The likelihood of PHI for a given lesion was 51% for IPCH, 22% for EDH, 17% for SAH, and 11% for SDH. Of the 46 patients who underwent craniotomy for hematoma evacuation, 24% did so after the second CT scan because of findings of PHI. Logistic regression was used to identify male sex (p = 0.01), older age (p = 0.01), time from injury to first CT scan (p = 0.02), and initial partial thromboplastin time (PTT) (p = 0.02) as the best predictors of PHI. The percentage of patients with mean daily ICP greater than 20 mm Hg was higher in those with PHI compared with those without PHI. The 6-month postinjury outcome was similar in the two patient groups. CONCLUSIONS: Early progressive hemorrhage occurs in almost 50% of head-injured patients who undergo CT scanning within 2 hours of injury, it occurs most frequently in cerebral contusions, and it is associated with ICP elevations. Male sex, older age, time from injury to first CT scan, and PTT appear to be key determinants of PHI. Early repeated CT scanning is indicated in patients with nonsurgically treated hemorrhage revealed on the first CT scan.     

Motorcycling and head injury: admissions to a regional head injury unit

In a 5-year period during which 7,178 patients with head injury were admitted to a regional head injury unit, 191 motorcyclists (2.7%) were admitted with head injuries of which 76% were classified as minor, 6% as moderate and 18% as severe (in coma). Two thirds of the patients were aged 20 years or less. Eighty-two riders (43%) had some form of facial or scalp trauma and 37 (19%) sustained skull fracture. Intracranial haematomas requiring surgical evacuation were detected in 3 of the minor head injuries (2%), 2 of the moderate injuries (17%) and 11 of the severely head injured patients (32%). Twenty-nine of the 34 severely injured patients were managed using artificial ventilation and intracranial pressure monitoring. The remaining patients died before these measures could be instituted. Overall mortality was 7%, but deaths were restricted to the severely head injured, among whom there were 13 fatalities. Head injuries associated with motorcycle riding include an unduly high proportion of severe cases and occur in a young population, often within a short time of starting to ride a motorcycle. Protective headgear was virtually always worn (94%); to reduce morbidity further, increased training and supervision during the first 6 months of motorcycle ownership should be emphasized.     

Paediatric head injury: incidence, aetiology and management

Trauma is the commonest cause of hospital admission in children. Head injuries are present in 75% of children with trauma and 70% of all traumatic deaths are due to the head injury. The mechanism of brain injury is examined, resulting from the effects of the primary insult and secondary ischaemic damage. Therapeutic interventions will be discussed with specific emphasis on outcome studies. However, institution of adequate oxygen delivery and haemodynamic stability in the child at the earliest moment remains the most important aspect of the management plan.     

Leukopenia secondary to silver sulfadiazine: frequency, characteristics and clinical consequences

Leukopenia associated with silver sulfadiazine (SSD) is a frequent event and may be a risk factor for infectious complications in the burn patient. This study reviews 77 patients with thermal injuries to determine total body surface area (BSA) burned, and white blood cell count (WBC) at time of hospital admission. A subpopulation of 56 patients with serial WBC counts were evaluated to determine lowest WBC count, topical burn therapy, episodes of infection or septic shock and final outcome. There was not a significant incidence of leukopenia on admission. Fifty-six per cent of patients treated with SSD and 12 per cent of silver nitrate-treated patients became leukopenic (P less than .05). The leukopenia was higher among SSD-treated patients who had greater than 15 per cent BSA burns (P less than .05). The onset of leukopenia generally occurred the second day after the burn and the WBC count returned to normal with discontinuance of the drug. The leukopenia was due primarily to a marked decrease in the number of mature neutrophils. There was no difference in the incidence of septic complications or opportunistic infections in the treatment groups. There was no significant difference in final outcome. Silver sulfadiazine-induced leukopenia appears to be a self-limited phenomenon that does not increase the incidence of infectious complications nor affect final outcome.     

Horse riding and head injury: admissions to a regional head injury unit

A retrospective survey has been carried out of 59 patients who suffered head injury related to horse riding out of 7172 cases of head and spinal injury admitted to a regional head injury unit in the 5-year period 1980-85. Most (85%) were female, against the usual 80% male predominance of head injury, 56 were minor injuries and 3 severe, of whom 2 died. Skull fracture was present in 10 patients (17%) of whom at least 5 had been wearing headgear at impact, and scalp trauma was noted in 22 (37%) with a predominance of occipital injuries. All the severely injured cases had an occipital skull fracture. One fifth of the patients suffered additional significant injuries. While most patients (90%) made a good recovery, 2 remained moderately and one severely disabled. Horse riding posed a significant risk of head injury to the population of riders, mainly young women. This survey suggests that the wearing of amateur riding headgear does not adequately protect the rider from scalp and skull injury, particularly in the occipital region.     

Right hepatic artery injury associated with laparoscopic bile duct injury: Incidence,mechanism, and consequences

Because most bile duct injuries involve the common hepatic duct, the right hepatic artery, which is nearby, can also be injured. Reports on the frequency and significance of right hepatic artery injury (RHAI) associated with bile duct injury are sparse but suggest that RHAI increases mortality and decreases the success of the biliary repair. We studied the incidence, mechanism, and consequences of RHAI accompanying major bile duct injury. A total of 261 laparoscopic bile duct injuries were analyzed. Distribution was as follows: class I, 6%; class II, 22%; class III, 61%; and class IV, 11%. RHAI was present in 84 cases (32%): class I, 6%; class II, 17%; class III, 35% (P < 0.04 vs. class I/II); and class IV, 64% (P < 0.007 vs. class I/II/III). RHAI was more commonly associated with abscess, bleeding, hemobilia, right hepatic lobe ischemia, and subsequent hepatectomy (54% with RHAI vs. 11% without RHAI; P < 0.0001). RHAI had no infiuence on the success of the bile duct injury repair or on the mortality rate. Complications occurred more often with RHAI among cases repaired by the primary surgeon (41% RHAIvs.2%no RHAI; P < 0.0001) but not among repairs by a biliary surgeon (3%RHAIvs.2%no RHAI, P = NS; P < 0.0001 primary vs. biliary surgeon). RHAI increased morbidity, and occurred more often with class III and IV injuries refiecting the mechanisms of these injuries. RHAI did not increase the mortality rate or alter the success of biliary repair. Among biliary injuries repaired by the primary surgeon, RHAI was associated with a higher incidence of postoperative abscess, bleeding, hemobilia, hepatic ischemia, and the need for hepatic resection. A similar increase in the complication rate was not seen in patients treated by a biliary specialist. Presented at the Forty-Fourth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Florida, May 18–21, 2003 (oral presentation).     

Minor,moderate and severe head injury

Summary The future role of the neurosurgeon in the management of head injury is reviewed in terms of the care of patients with minor, moderate and severe head injuries. In minor head injury it is predicted that there will be increasing pressure on the neurosurgeon to undertake the management and follow-up of all patients who have sustained head injury, and this will place a considerable additional load on each neurosurgical unit. This is based on a survey of 1919 head injuries admitted in one calendar year (1981), consisting of 93 severe injuries (GCS < 8), 210 moderate injuries (GCS 8–12), and 1616 minor injuries (GCS 13/14). In moderate injuries CT will assume a major role in detecting hematoma early and identifying contusions. There may yet be a role for steroids in these cases and there should be a greater use of neurorehabilitation, instead of the current overemphasis on the severely injured. In severe injury future efforts will be to prevent early secondary insults and to find better methods of controlling raised intracranial pressure.     

Hypotension and hypertension as consequences of baroreceptor dysfunction following carotid endarterectomy.

Arterial pressure regulation is often labile following carotid endarterectomy. Hemodynamic data from 100 consecutive endarterectomies allowed definition of three distinct postoperative blood pressure responses. A hypotensive response (group I) affected 28 patients in whom mean arterial pressure decreased from 168 +/- 29/90 +/- 15 mm Hg before operation to 110 +/- 21/68 +/- 16 mm Hg after operation (P less than 0.001). Maximum hypotension occurred 5.3 hours after endarterectomy. The preoperative pulse, 80 +/- 9 beats/min, fell to a low of 64 +/- 12 beats/min after operation (P less than 0.001). A significant hypertensive response (group II) affected 19 patients in whom mean blood pressure rose from 160 +/- 29/87 +/- 15 to 223 +/- 32/110 +/- 22 mm Hg (P less than 0.001). Maximum hypertension was noted 2.3 hours after endarterectomy. This was unaccompanied by significant pulse changes. Fifty-three patients remained normotensive (group III). Their preoperative blood pressure (150 +/- 14 mmHg). Fluctuations in pressure did not correlate with age, indication for operation, or degree of ipsilateral and contralateral carotid arterial stenosis. Postendarterectomy hypotension and hypertension appear to represent transient baroreceptor dysfunctions.     

Knee ligament injury, surgery and osteoarthrosis: Truth or consequences?

We reviewed reports that describe development of osteoarthrosis of the knee after anterior cruciate ligament or meniscus injury. The occurrence of posttraumatic osteoarthrosis varied considerably from one report to another. The literature does not lend support to the efficacy of cruciate ligament repair or reconstruction in retarding the progression of osteoarthrosis after knee injury. We encourage prospective, controlled, randomized and masked studies that aim to evaluate the utility of ligament reconstruction, meniscus suture or meniscus transplantation for preventing posttraumatic osteoarthrosis.     

Mild head injury: revisited

Summary Objective. 1. To define the incidence of positive CT scans in patients with different grades of mild head injury (MHI), 2. To identify clinical predictors of positive CT scans, 3. To evaluate the usefulness of plain radiographs in the triage of patients with MHI, 4. To evaluate frequency and nature of surgical intervention in MHI, 5. To evaluate the risk of deterioration in MHI, and 6. To find out whether patients with normal neurological examination and normal CT can be safely discharged.Methods. In a prospective study conducted over a period of four months in our center, all patients with mild head injury (defined as Glasgow Coma Scores (GCS) 13–15) were admitted to the head injury unit. Patients underwent standard clinical examination, skull radiography and cranial CT. No clinical criteria were used to select patients for CT scanning and all the patients were subjected to CT. Patients with negative findings on CT and a normal neurological examination were discharged after 24 hours of observation. Patients with positive findings on cranial CT were treated either medically or surgically as deemed necessary. Outcome measures included safe discharge, clinical deterioration, need for surgical intervention or death. The following factors were analyzed statistically to find out whether they can be used as predictive factors for positive cranial CT. They were: age, sex, mode of injury, loss of consciousness, post-traumatic seizures, ear/ nose/throat bleeding, vomiting, admission GCS score, scalp injury, polytrauma, focal neurological deficit, fractures visualized on skull radiography.Results. Three hundred and eighty one patients were included in the study. Of these males constituted 63%, females 17% and children 20%. RTA was the most common mode of injury. Seventy five percent of the patients had GCS of 15, 15% had GCS of 14 and 10% had GCS of 13. Thirty eight percent of the patients had positive findings on the CT. Age, mode of injury, loss of consciousness, post-traumatic seizures, ENT bleeding, vomiting, scalp injury and polytrauma were not found to be predictors of positive CT. Admission GCS score, focal neurological deficits, and fractures detected by skull radiography were found to be statistically significant predictors of positive findings on CT. Seven percent of patients required surgical intervention. Six percent of patients showed neurological deterioration and there was one death in this series of MHI patients. Patients with multiple lesions on CT had a higher chance of deterioration than those with a single lesion. No patient who had a GCS of 15 and normal CT developed any complication during the hospital stay or after discharge.Conclusions. The incidence of positive CT scans in this prospective, consecutive, unselected cohort of MHI patients was 38%. Lower admission GCS scores, focal neurological deficits, and fractures detected by skull x-rays were found to be significant predictors of positive CT. Other clinical parameters were not found to be predictors of positive CT. CT was found to be superior to plain x-rays in detecting skull fractures. Seven percent of this cohort required neurosurgical intervention. Six percent showed neurological deterioration and there was one death in this series. Patients with multiple lesions on CT had a higher chance of deterioration than those with single lesions. The duration of hospital stay was prolonged in patients with positive CT. As no patient with a normal neurological examination and a normal CT deteriorated, we believe these patients can be safely discharged without need for admission and observation.