Outcome of traumatic extradural haematoma in Hong Kong

AIM: Traumatic extradural haematoma (EDH) is a neurosurgical emergency and timely surgical intervention for significant EDH is the gold standard. This study aims to determine the incidence and mortality of consecutive patients with traumatic EDH admitted to the Emergency Department (ED) of Prince of Wales Hospital (PWH), a University Hospital Trauma Centre in Hong Kong. PATIENTS AND METHODS: Retrospective analysis of prospectively collected data for all consecutive trauma cases admitted through the ED during 2001-2004. EDH was diagnosed by CT in all cases. Both primary and delayed onset EDH were included, as were patients with combined EDH and other intracranial lesions (e.g. subdural haematoma). Age, sex, cause of injury, associated intracranial lesions, skull fracture, Glasgow Coma Scale, pupil reactivity, treatment, length of stay and clinical outcome were determined. RESULTS: Two thousand and two hundred and eight patients were in the trauma registry for 2001-2004. Total 1080 head injured patients; 89 patients had traumatic EDH, mean of 1.9 patients per month. Seventy (79%) patients were male, with a mean age of 37.7 years. Fifty (56%) patients were from road traffic crashes, 27 (30%) sustained falls, 10 (11%) had direct head trauma. On admission, 62 (70%) patients were GCS 13-15, 9 (10%) GCS 9-12 and 18 (20%) GCS 3-8. Sixty-six (74%) patients had a skull fracture. Thirty (34%) patients underwent neurosurgical operation. Overall, nine patients (10%) died; eight patients were GCS<8; five had bilateral fixed and dilated pupils; one had a single fixed and dilated pupil. Four patients died after neurosurgical operation, three of whom had fixed dilated pupils and were GCS 3 prior to surgery. Median length of hospital stay for survivors was 10.4 days. CONCLUSION: Survival from traumatic EDH was 90% (80/89) and 91% (73/80) of survivors had a Glasgow Outcome Score of 4 or 5 (good or moderate). The combination of bilateral fixed dilated pupils and GCS 3 suggests severe primary brain injury. Emergency evacuation of intracranial haematomas is unlikely to improve the outcome for these patients. Even in an urban environment with short prehospital times and rapid access to neurosurgery, outcome in patients who are GCS 3 following EDH is likely to be poor.     

Who should be hospitalized following mild craniocerebral trauma?]

The frequency of minor closed head injuries is high. These injuries may be complicated by the development of life-threatening intracranial hematomas. A well-defined selection criteria for admission must be proposed to guarantee an efficacious observation. In our series of 489 hospitalized patients with a GCS of 15 when seen in the emergency room: 4 patients required evacuation of an intracranial hematoma, 11 revision of a depressed skull fracture or a compound fracture of base of the anterior fossa. Using the existence of a skull fracture as a selection for admission, a strategy proposed by Jennett and colleagues, it would have been possible to reduce the number of patients hospitalized by 70% without missing a patient who developed an intracranial hematoma. Following these criteria no intracranial hematoma would be missed in our patients with a GCS of 15. We suggest that the use of plain x-rays to identify skull fractures and subsequent hospitalization prevents missing an intracranial hematoma. Those patients with diminished levels of consciousness of focal neurologic deficits require admission irrespective of skull fractures.     

Correlation between the skull base fracture and the incidence of intracranial hemorrhage in patients with traumatic brain injury

Purpose: A head injury (HI) may cause a skull fracture, which may or may not be associated with injury to the brain. In essence, a skull base fracture (SBF) is a linear fracture at the base of the skull. Loss of consciousness and Glasgow coma score (GCS) may vary depending on an associated intracranial pa thology. The pathomechanism is believed to be caused by high energy impact directly to the mastoid and supraorbital bone or indirectly from the cranial vault. Aim of this study is to define the correlation be tween SBF and intracranial hemorrhage (ICH) in patients with HI. Methods: Analysis of data obtained from a retrospective review of medical records and from a system atized database pertaining to diagnostic criteria of SBF patients based only on clinical symptoms asso ciated with ICH caused by HI treated in the Department of Neurosurgery at Dr. Hasan Sadikin Hospital, Bandung, Indonesia from January 1, 2012 to December 31, 2017. The exclusion criteria included age less than 15 years and no head computed tomography (CT) scan examination provided. Results: A total of 9006 patients were included into this study in which they were divided into 3 groups: group 1, HI with no ICH; group 2, HI with single ICH and group 3, HI with multiple ICH. In all the SBF cases, SBF at anterior fossa accounted for 69.40% of them, which were mostly accompanied with mild HI (64.70%). Severity of HI and site of SBF correlated with the existence of traumatic brain lesions on CT scan, thus these factors were able to predict whether there were traumatic brain lesions or not. Most of the patients with epidural hemorrhage (EDH) has single traumatic lesion on CT scan, whereas most of the patients with cerebral contusion (CC) has multiple traumatic lesions on CT scan. On patients with both traumatic brain injury and SBF, most of the patients with anterior fossa SBF has EDH; whereas most of the patients with middle fossa SBF were accompanied with CC. Surgery was not required for most of the patients with SBF. Conclusion: SBFs were strongly correlated with traumatic ICH lesions patients with anterior fossa SBF were more likely to suffer EDH whereas with middle fossa SBF were more likely to suffer CC.     

Posterior fossa extradural hematoma: our experience and review of the literature

BACKGROUND: Posterior fossa EDH is an uncommon entity, accounting for only 4% to 12.9% of all EDHs It has a characteristic clinical presentation, which if detected can be life-saving. METHODS: We sought to study the demographic features of patients with PFEDH and assess the clinical and radiologic predictors of the outcomes of as well as evaluate the various treatment modalities for this disease. We carried out a retrospective analysis of the cases of 61 patients with PFEDH who were admitted to the National Institute of Mental Health and Neurosciences (Bangalore, India) from 1991 through 2002. We analyzed various parameters and applied Fisher's exact test for statistical analysis. RESULTS: Mostly male individuals were affected with PFEDH. Their GCS score at admission and the presence of hydrocephalus as detected by CT scan determined the outcome of the patients. The children had better outcomes than did the adults. Patients with a good GCS score could be managed conservatively. CONCLUSIONS: Posterior fossa EDH is rare. The PF is an unfavorable location of a hematoma. Good GCS scores have a favorable prognosis. Children have better outcomes than do adults, and the presence of hydrocephalus on CT scan is an ominous sign.     

Minimal head injury: is admission necessary?

The records of 138 patients admitted a Glasgow Coma Score (GCS) of 14 or 15 following head injury were reviewed to assess the need for hospital observation and to determine whether obtaining a normal computerized tomography (CT) scan in the emergency department could have avoided admission. GCS was 15 in 103 patients (74%) and 14 in 35 (26%). Eighty-three patients were admitted for their head injury alone, and 55 had other injuries but would have required admission for their head injury. Loss of consciousness was documented in 51 per cent and suspected in another 29 per cent and was distributed equally regardless of GCS. Seven per cent (5/71) of skull x rays were positive and were associated with CNS pathology in three patients. Skull x rays in an additional four patients with positive CT findings were negative including a patient with an epidural hematoma (EDH). Seventeen per cent (13/75) of CT scans were positive (contusions 5, subdural hematoma 3, subarachnoid hemorrhage 2, edema 2, EDH 1). Only the patient with the EDH required operative treatment. No patient with a normal CT scan went on to develop any neurosurgical problems, and 78 per cent of the patients admitted with isolated head injuries were discharged within 48 hours. Significant CNS pathology does occur following "minimal" head injuries. Skull x rays are not helpful. The use of CT scanning appears to triage those patients requiring admission and in hospital observation.     

Quality assurance for patients with head injuries admitted to a regional trauma unit

The efficacy of trauma systems in reducing preventable deaths has been established but the methods of auditing care are still evolving. Various "audit filters" to identify which patients' charts should be reviewed have been proposed. An analysis of all patients admitted to the Regional Trauma Unit (RTU) over a 19-month period was conducted. Of 729 patients, 135 were identified as having suffered a traumatic intracranial hemorrhage (TICH). On review, neither delay in transfer from the emergency room to the operating room nor increasing time from the incident to the operating room correlated with increasing mortality. In contrast to delay, the Glasgow Coma Scale (GCS) score on admission correlated well with outcome. The charts of patients with anomalous outcomes based on admission GCS score were reviewed, and two possibly preventable deaths were identified. There were 48 patients with TICH who had no operations but there were no deaths attributable to a missed operation. There were 76 patients for whom the GCS score at the referring hospital and the GCS score on admission to the RTU were available. Seven of 19 patients who worsened on transfer declined because of significant pulmonary injuries. Anomalous outcomes based on admission GCS score and declining GCS scores are recommended as quality assurance filters.     

Computed tomography of the brain in predicting outcome of traumatic intracranial haemorrhage in Malaysian patients

Summary  Head injury is a significant economic, social and medical problem all over the world. Road accidents are the most frequent cause of head injury in Malaysia with highest risk in the young (15 to 24 years old). The associated outcomes include good recovery, possibility of death for the severely injured, which may cause disruption of the lives of their family members. It is important to predict the outcome as it will provide sound information to assist clinicians in Malaysia in providing prognostic information to patients and their families, to assess the effectiveness of different modes of treatment in promoting recovery and to document the significance of head injury as a public health problem.  Results. A total of 103 cases with intracranial haemorrhage i.e. intracerebral haemorrhage, extradural haemorrhage, subdural haemorrhage, intraventricular haemorrhage, haemorrhagic contusion and subarachnoid haemorrhage, following motor vehicle accidents was undertaken to study factors contributing to either good or poor outcome according to the Glasgow Outcome Scale. Patients below 12 years of age were excluded. The end point of the study was taken at 24 months post injury.  The selected variables were incorporated into models generated by logistic regression techniques of multivariate analysis to see the significant predictors of outcome as well as the correlation between the CT findings with GCS.  Conclusion. Significant predictors of outcome were GCS on arrival in the accident emergency department, pupillary reflex and the CT scan findings. The CT predictors of outcome include ICH, EDH, IVH, present of SAH, site of ICH, volumes of EDH and SDH as well as midline shift.     

Prognostic value of early computerized tomography scanning following craniotomy for traumatic hematoma.

OBJECT: Patients with head injuries traditionally were categorized on the basis of whether their lesions appeared to be diffuse, focal, or mass lesions on admission computerized tomography (CT) scanning. In the classification of Marshall, et al., the presence of a hematoma (evacuated or not evacuated) is more significant than any diffuse injury (DI). The CT scan appearance after evacuation of a mass lesion has not been analyzed previously in relation to outcome. The authors have investigated the importance of: 1) neurological assessment at hospital admission; 2) the status of the basal cisterns and associated intracranial lesions on the admission CT scan; and 3) the degree of DI on the early CT scan obtained after craniotomy to identify patients at risk for development of raised intracranial pressure (ICP) and lowered cerebral perfusion pressure (CPP) and to discover the influence of the postoperative CT appearance of the lesion on patient outcome. METHODS: The authors prospectively studied 82 patients with isolated, severe closed head injury (Glasgow Coma Scale [GCS] score < or = 8), all of whom had intracranial hematoma. Both ICP and CPP were continuously monitored, and a CT scan was obtained within 2 to 12 hours after craniotomy. The CT images were categorized according to the classification of Marshall, et al. The mortality rate during the hospital stay was 37%, and 50% of the patients achieved a favorable outcome. Compression of the basal cistern on the admission (preoperative) CT scan was associated with raised ICP and a CPP of less than 70 mm Hg but not with any other features or with poor patient outcome. In 53 patients the postoperative CT scan revealed DIs III or IV and 29 patients had DIs I or II. The percentages of time during the hospital stay in which ICP was higher than 20 mm Hg and CPP was lower than 70 mm Hg as well as unfavorable outcome were higher in the group of patients in whom DI III or IV was present (p < 0.001). Raised ICP, CPP lower than 70 mm Hg, DI III or IV, and unfavorable outcome were more frequently observed in patients who presented with a motor (m)GCS score of 3 or less, bilateral unreactive pupils, associated intracranial injuries, and hypotension (p < 0.001). When logistic regression analysis was performed, an mGCS score of 3 or less (p = 0.0013, odds ratio [OR] 10.8), bilateral unreactive pupils (p = 0.0047, OR 31.8), and DI III or IV observed on CT scanning after surgery (p = 0.015, OR 8.9) were independently associated with poor outcome. CONCLUSIONS: Features on CT scans obtained shortly after craniotomy constitute an independent predictor of outcome in patients with traumatic hematoma. Patients in whom DI III or IV appears on postoperative CT scanning, who often present with an mGCS score of 3 or less and nonreactive pupils, are at high risk for the development of raised ICP and lowered CPP.     

A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale score of 13-14)

OBJECTIVE: Considerable controversy surrounds the appropriate evaluation of children with mild alterations in consciousness after closed head trauma (Glasgow Coma Scale [GCS] score of 13-14). The objective of the current study was to determine the incidence of intracranial lesions in pediatric patients with a field GCS score of 13 or 14 after closed head injuries. METHODS: The current study is a population-based, multicenter prospective study of all patients to whom emergency medical services responded during a 12-month period. The setting was urban Los Angeles County, encompassing a patient population of 2.3 million children, 13 designated trauma centers, and 94 receiving hospitals. RESULTS: In the pediatric age group (<15 yr old), 8488 patients were transported by emergency medical services for injuries. Of these, 209 had a documented field GCS score of 13 or 14. One hundred fifty-seven patients were taken to trauma centers, and 135 (86%) underwent computed tomography. Forty-three patients (27.4%) had abnormal results on computed tomographic scans, 30 (19.1%) had an intracranial hemorrhage, and 5 required an operative neurosurgical procedure for hematoma evacuation. Positive and negative predictive values of deteriorating mental status (0.500 and 0.844, respectively), loss of consciousness (0.173 and 0.809), cranial fracture (0.483 and 0.875, and extracranial injuries (0.205 and 0.814) were poor predictors of intracranial hemorrhage. CONCLUSION: Pediatric patients who have mild alterations in consciousness in the field have a significant incidence of intracranial injury. The great majority of these patients will not require operative intervention, but the implications of missing these hemorrhages can be severe for this subgroup of head-injured patients. Because clinical criteria and cranial x-rays are poor predictors of intracranial hemorrhage, it is recommended that all children with a GCS score of 13 or 14 routinely undergo screening via non-contrast-enhanced computed tomography.     

Acute subdural hematoma: Outcome and outcome prediction

Patients with traumatic acute subdural hematoma were studied to determine the factors influencing outcome.Between January 1986 and August 1995, we collected 113 patients who underwent craniotomy for traumatic acute subdural hematoma. The relationship between initial clinical signs and the outcome 3 months after admission was studied retrospectively.Functional recovery was achieved in 38% of patients and the mortality was 60%. 91% of patients with a high Glasgow Coma Scale (GCS) score (9–15) and 23% of patients with a low GCS score (3–8) achieved functional recovery. All of 14 patients with a GCS score of 3 died. The mortality of patients with GCS scores of 4 and 5 was 95% to 75%, respectively. Patients over 61 years old had a mortality of 73% compared to 64% mortality for those aged 21–40 years. 97% of patients with bilateral unreactive pupil and 81% of patients with unilateral unreactive pupil died. The mortality rates of associated intracranial lesions were 91% in intracerebral hematoma, 87% in subarachnoid hemorrhage, 75% in contusion.Time from injury to surgical evacuation and type of surgical intervention did not affect mortality. Age and associated intracranial lesions were related to outcome. Severity of injury and pupillary response were the most important factors for predicting outcome.     

Traumatic epidural haematomas of the posterior fossa: 20 new cases and a review of the literature since 1961

Twenty patients with an epidural haematoma of the posterior fossa (EPIPF) among a total number of 359 patients with an epidural haematoma are reported (5.6%). Nine patients obtained a good outcome, four patients had a moderate disability and seven patients died (mortality 35%). Mortality of the acute cases was 50%, of the subacute cases 20%. In general, the clinical features were uncertain. Sixteen cases showed an occipital skull fracture or diastasis of the lambdoid suture respectively. A total number of 127 cases with EPIPF from the literature since 1961 was studied. The mortality in the CT-diagnosed group ran to 21.7% and to 25.9% in the group without CT. None of the patients showing a subacute course died when the diagnosis was made by CT, in the group without CT, however, four patients out of 11 subacute cases died. Head injured patients with an occipital trauma should therefore undergo CT scanning to detect a surgically significant lesion before clinical deterioration occurs.     

Vertex epidural hematoma: Diagnosis,therapeutic consideration and outcome

ObjectiveVertex epidural hematoma (VEDH) is a relatively uncommon type of intracranial hematoma. Because of its unique location and the potential of massive intraoperative bleeding, diagnosis and surgical intervention of VEDH may be challenging.Materials and methodsA retrospective analysis of 32 patients with VEDH was undertaken to investigate the prognostic factor and therapeutic strategy of VEDH. Special attention was paid to the relationship between fracture pattern, surgical method, intraoperative blood loss and outcome.ResultsPatients treated surgically had a higher percentage of consciousness disturbance and a significantly larger size of VEDH compared with patients treated conservatively (p = 0.029 and p < 0.0001, respectively). Bleeding from the injured superior sagittal sinus (SSS) was noted in six of nine patients (67%) with a linear fracture parallel to the SSS. Only one patient (20%) with a linear fracture crossing the SSS had bleeding from the injured SSS. Five of eight patients (63%) with sagittal suture diastasis experienced bleeding from the SSS. All patients with massive blood loss and six of seven patients developing intraoperative shock had copious bleeding from the injured SSS. All patients with intraoperative massive bleeding and shock underwent traditional “simple craniotomy”. No patients undergoing “strip craniotomy” experienced massive bleeding. Thrombocytopenia (p = 0.008), headache (p = 0.015), consciousness disturbance (p = 0.043), pupil reactivity (p = 0.010), GCS score (p < 0.0001) and the relationship between skull fracture and the SSS (p = 0.037) were significant prognostic factors.ConclusionOur study demonstrated GCS score may be a significant prognostic factor in patients with VEDH. Bleeding from the injured SSS occurred frequently in VEDH patients with a linear skull fracture parallel to the SSS or sagittal suture diastasis and could cause devastating hemorrhage. When operating on such patients, the surgical team should prepare for the possibility of massive blood loss and intraoperative shock. Bilateral parasagittal craniotomies with preservation of a central bone strip containing the sagittal suture (strip craniotomy) to allow application of tack-up sutures from the dura to the bone strip may be more suitable for VEDH evacuation.     

The significance of skull fracture in acute traumatic intracranial hematomas in adolescents: a prospective study

A prospective study was conducted to validate the retrospective finding that adolescents (11 to 15 years old) with skull fractures were prone to develop acute traumatic intracranial hematoma (ICH). Over a 4-year period, 1178 consecutive adolescents attended the emergency room directly, of whom 760 were discharged well and 418 were admitted. All underwent skull x-ray studies. Immediate computerized tomography (CT) scans were performed in patients with Glasgow Coma Scale (GCS) scores of less than 15, in those with radiological and/or clinical evidence of skull fracture, and whenever clinically indicated. Of the 418 admitted patients, only 26 had skull fractures; 13 of these developed ICH. Four patients without skull fracture developed diffuse brain swelling. The remaining 401 patients were discharged after observation periods of up to 48 hours. Of the 13 patients with ICH, 10 had admission GCS scores of 15; however, four deteriorated rapidly and required urgent operation, and four remained stable but were operated on due to their large ICH. Two required conservative treatment only and both made good recovery. Three patients were in coma (GCS score less than or equal to 8) on admission. One patient had an epidural hematoma and made good recovery after surgery. Two developed delayed ICH after operations for associated systemic injuries despite initial CT showing diffuse brain swelling only, and both died despite evacuation of the ICH. Multivariate analysis showed that skull fracture was the only independent significant risk factor in predicting ICH in adolescents (sensitivity of 100% and specificity of 97%). A routine skull x-ray study is therefore mandatory in all head-injured adolescents and, if a skull fracture is detected, immediate CT may be performed for early detection of ICH.     

Penetrating orbitocranial gunshot injuries

BACKGROUND: The aim of this study was to analyze the effect of a surgical management protocol and other important clinical features on the prognosis of patients who had penetrating orbitocranial gunshot injuries. METHODS: Thirty-five patients (30 unilateral, 5 bilateral) who had penetrating orbitocranial gunshot injuries were analyzed. The wounds were mainly caused by shrapnel fragments or bullets. Craniotomy was the standard treatment in all patients. Investigated clinical features included Glasgow Coma Scale (GCS) score on admission, the mode and the extent of brain injury, and the presence of an intracranial retained foreign body. The prognostic importance of complications such as infection, intracranial hemorrhage, cerebrospinal fluid leak, and epileptic seizures was also investigated. The mechanism and the injury characteristics of the patients were evaluated by predicting the visual outcome of the victims according to a newer classification system as well as other variables pertinent to this specific clinical setting of severe eye trauma. Final visual acuities of the patients were also measured. RESULTS: The outcome of 35 penetrating orbitocranial gunshot injured patients was as follows: death in 3 patients, vegetative state in 1, severe disability in 2, moderate disability in 2, and good recovery in 27 cases. Localization and extent of the injury and GCS score on admission were the most important indicator for good neurological outcome. The predictors for good visual outcome were type B, grade 1, zone I, and relative afferent pupillary defect-negative injuries. The predictors for poor outcome were type A, grade 5, zone III, and relative afferent pupillary defect-positive injuries. CONCLUSION: The prognosis of the injury depends on the course of the bullet or shrapnel fragment and the interdisciplinary care. An extensive preoperative evaluation of penetrating orbital trauma and a combined ophthalmic and neurosurgical approach are recommended to minimize the morbidity of the patients. However, complete removal of the foreign material in a deep or ventricular localization is not mandatory because careful debridement and tight closure of dura provides desired outcome. Evaluation of trauma mechanism and injury characteristics according to the Ocular Trauma Classification System seems to predict accurately the visual outcomes in this series.     

Pediatric minor head trauma: indications for computed tomographic scanning revisited

BACKGROUND: Although the use of computed tomographic (CT) scanning in severe head trauma is an accepted practice, the indications for its use in minor injury remain ill defined and subjective. We sought to define the incidence and identify risk factors for intracranial injury (ICI) after minor head trauma in children who did not have suspicious neurologic symptoms in the field or on presentation. METHODS: From January 1, 1992, until April 1, 2000, 569 blunt trauma patients (age < 16 years) with a Glasgow Coma Scale score of 14 or 15 triaged by American College of Surgeons Pediatric Mechanism Criteria at a Level I trauma center received head CT scan. Loss of consciousness (LOC) status was known for 429. This subgroup was retrospectively reviewed for mechanism, age, Injury Severity Score, LOC status, GCS score, associated injuries, and CT scan findings (normal, fracture only, or intracranial injury). Relative risk values for intracranial injury were generated and statistical significance was assessed. RESULTS: Fourteen percent (62 of 429) of study patients (GCS score of 14 and 15) had ICI. Sixteen percent of patients (35 of 215) with GCS score of 15 and (-)LOC (negative for LOC) had intracranial injury manifesting as subdural hematoma, epidural hematoma, subarachnoid hemorrhage, or brain contusion. Three required surgery for intracranial mass lesions. One patient deteriorated and required intubation and intensive care unit management. Neither (+)LOC (positive for LOC) nor GCS score of 14 increased the likelihood of intracranial injury over those patients without loss of consciousness or with GCS score of 15. Distant injury was also not an independent predictor of ICI for those with GCS scores of 14 or 15, as 84% of the ICI group had head injury only. Skull fracture was a risk factor for ICI but had poor negative predictive value, as 45% of patients with ICI did not have fractures. Similarly, minor craniofacial soft tissue trauma was a significant risk factor (relative risk, 11) that had marginal negative predictive value (0.95), as 14% (9 of 62) of ICI patients did not have superficial craniofacial injury. CONCLUSION: A normal neurologic exam and maintenance of consciousness does not preclude significant rates of intracranial injury in pediatric trauma patients. Contrary to convention, neither LOC nor mild altered mentation is a sensitive indicator with which to select patients for CT scanning. Skull fractures and superficial craniofacial injury are similarly unreliable. Identification of these patients is important for the occasional case requiring intervention and for the tracking of complications. A liberal policy of CT scanning is warranted for pediatric patients with a high-risk mechanism of injury despite maintenance of normal neurologic status in the field and at hospital screening.     

Effect of high-dose dexamethasone on outcome from severe head injury

The conflicting evidence concerning the influence of high-dose steroids on intracranial pressure (ICP) and outcome following severe head injury has led to the institution of the prospective double-blind controlled trial reported here. Severely head-injured patients admitted to intensive care during a 3-year period were randomly allocated to a dexamethasone- or placebo-treated group. Adults in the steroid group received dexamethasone, 50 mg intravenously, as a bolus on admission to the neurosurgical unit, then 100 mg on Days 1, 2, and 3, 50 mg on Day 4, and 25 mg on Day 5 on continuous intravenous infusion. Children received proportionate intravenous dosages calculated on a weight basis. Severity of head injury was assessed from admission Glasgow Coma Scale (GCS) scores and the appearance of the admission computerized tomography scan. Intracranial pressure (ICP) was monitored in all patients from the surface subarachnoid space. Outcome at 6 months was assessed using the Glasgow Outcome Scale. Steroid and placebo groups were similar in terms of admission GCS score, intracranial pathology, incidence of associated injuries, and time interval from injury to admission to intensive care. The ICP generally increased during the first 48 hours of intensive therapy; there was no difference in this trend between the steroid and placebo groups. A poorer outcome was observed in patients with elevated ICP who received steroids. No increase in the incidence of pulmonary, gastrointestinal, or other extracranial complications was seen in the steroid group. The 6-month outcome did not differ between the steroid and placebo groups. No advantage of high-dose dexamethasone on ICP trends or clinical outcome in the treatment of severe head injury has emerged from this study.     

Early prediction of mortality in isolated head injury patients: a new predictive model

BACKGROUND: To construct a predictive model of survival in isolated head injury patients, on the basis of easily available parameters that are independent risk factors for survival outcome. METHODS: Trauma registry-based study of head injury patients who had no other major extracranial injuries and were not hypotensive at admission. A predictive model of probability of death was constructed using discriminant analysis, on the basis of admission Glasgow Coma Scale (GCS) score, head Abbreviated Injury Score (AIS), age, and mechanism of injury. RESULTS: The study included 7,191 patients with head trauma. The overall correct classification rate of the proposed predictive model was 94.2% as compared with 89.0% of the admission GCS score (p < 0.05) and 92.8% of the head AIS (p < 0.05). The correct classification rate of the predictive model developed for the severe head trauma (GCS score 4-8) patients was 79.9%, as compared with 72.6% using the admission GCS score alone or 75.1% (p < 0.05). A one-page, easy to use table summarizing the predicted mortality on the basis of GCS score, head AIS, mechanism of injury, and age was developed. CONCLUSIONS: The proposed model has a significantly better predictive power, especially in severe head trauma, than the extensively used GCS and head AIS. A simple table on the probability of death of a particular patient based on admission GCS score, head AIS, mechanism of injury and age of patient can provide instant information.     

Usefulness of the abbreviated injury score and the injury severity score in comparison to the Glasgow Coma Scale in predicting outcome after traumatic brain injury

BACKGROUND: Assessment of injury severity is important in the management of patients with brain trauma. We aimed to analyze the usefulness of the head abbreviated injury score (AIS), the injury severity score (ISS), and the Glasgow Coma Scale (GCS) as measures of injury severity and predictors of outcome after traumatic brain injury (TBI). METHODS: Data were prospectively collected from 410 patients with TBI. AIS, ISS, and GCS were recorded at admission. Subjects' outcomes after TBI were measured using the Glasgow Outcome Scale (GOS-E) at 12 months postinjury. Uni- and multivariate analyses were performed. RESULTS: Outcome information was obtained from 270 patients (66%). ISS was the best predictor of GOS-E (rs = -0.341, p < 0.001), followed by GCS score (rs = 0.227, p < 0.001), and head AIS (rs = -0.222, p < 0.001). When considered in combination, GCS score and ISS modestly improved the correlation with GOS-E (R = 0.335, p < 0.001). The combination of GCS score and head AIS had a similar effect (R = 0.275, p < 0.001). Correlations were stronger from patients 8). CONCLUSIONS: GCS score, AIS, and ISS are weakly correlated with 12-month outcome. However, anatomic measures modestly outperform GCS as predictors of GOS-E. The combination of GCS and AIS/ISS correlate with outcome better than do any of the three measures alone. Results support the addition of anatomic measures such as AIS and ISS in clinical studies of TBI. Additionally, most of the variance in outcome is not accounted for by currently available measures of injury severity.     

The value of the Glasgow Coma Scale and Injury Severity Score: predicting outcome in multiple trauma patients with head injury

This retrospective study of multiple trauma patients requiring SICU admission was undertaken to determine to what extent, if any, head injury affected patient outcome. One hundred seventy such patients with head injuries had further analysis. Glasgow Coma Scale (GCS) values at approximately 5 hours postinjury were evaluated, and the Glasgow Outcome Scale was determined 1 month postinjury. A good recovery was seen in 99% of the 87 patients with GCS 15-13. This fell to 71% of the 24 patients with GCS 12-9. Among 59 patients having a GCS below 9, 41% died and an additional 17% had a poor recovery, leaving only 35% with an eventual good outcome. By using both Injury Severity Score and GCS at 6 hours postinjury, physicians will be more accurate in assessing outcome of multiple trauma patients with head injuries.     

Analysis of 76 civilian craniocerebral gunshot wounds

A retrospective analysis of 76 civilian craniocerebral gunshot wounds treated over a 20-month period is presented. The authors report a 62% mortality rate and conclude that the admission Glasgow Coma Scale (GCS) score is a valuable prognosticator of outcome. Other important findings were: patients with a GCS score of 3 invariably died, with or without surgical intervention; and the presence of intracranial hematomas, ventricular injury, or bihemispheric wounding was associated with a poor outcome. Standardized methods of data reporting should be adopted in order to allow multicenter trials or comparisons that might lead to management practices that could improve results.