Abstract
BackgroundHistorically neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression. Underpinning this is an assumption that these patients have a better outcome than patients without a surgical lesion. This has meant that many patients without a surgical lesion have been managed locally in the referring hospital. However, there is now evidence that treatment of all head injured patients in a specialist centre leads to improved outcomes. Therefore, we have asked the question: does the presence of a surgical lesion imply better outcome from severe head injury?ResultsWe prospectively recorded the Glasgow Outcome score (GOS), at 3 months, of all the severely head injured patients treated at our institution over a two and a half year period. Of 116 patients admitted with an initial Glasgow Coma Score (GCS) of 8 or less, 58 had surgical lesions and 58 non-surgical head injuries. The two groups were well matched for presenting GCS and age. Overall our favourable outcome rate (GOS 4 and 5) at 3-months for the patients with a surgical lesion and for the non-surgical group were 47.3% and 46.6% respectively, with no significant difference between the two (P = 0.54).ConclusionThe assumption in the past has always been that patients presenting in coma from traumatic diffuse brain injury will do worse than those that have a mass lesion amenable to surgical decompression. Our series would suggest that this is not the case and all severely head injured patients should expect similar outcome when cared for in a neuroscience centre.
Highlights
Neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression
Study Cohorts Over the study period 116 patients with an initial Glasgow Coma Score (GCS) of eight or less were admitted to Greater Manchester Neuroscience Centre
We have demonstrated that a favourable outcome (GOS 4 or 5) for patients with non-surgical severe traumatic brain injury (46.6%) was not significantly different to the outcome for patients in the surgical cohort (47.3%) (P = 0.54)
Summary
Neurosurgeons have accepted head injured patients only in the presence of a mass lesion requiring surgical decompression Underpinning this is an assumption that these patients have a better outcome than patients without a surgical lesion. It is well accepted that prompt surgical decompression of traumatic intracranial haematomas leads to improved outcomes for head injured patients. Due to lack of infrastructure, patients deemed to have non-surgical head injuries have often been managed outside of neuroscience centres. This approach to allocating limited resources is based on a long-held belief that individuals with focal surgical lesions will do better than those with diffuse injuries. This is intuitive because an EDH compromises neural function by compression, but often has minimal associated underlying parenchymal injury; prompt surgical evacuation will lead to a good recovery
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