Outcome Of Head Injury Research Articles

The relation between intracranial pressure and outcome in non-accidental head injury.

The aim of this retrospective study was to ascertain whether physiological derangement and potential secondary brain insult from raised intracranial pressure (ICP) or reduced cerebral perfusion pressure (CPP) in non-accidental head injury (NAHI) influences outcome. Any child who had a diagnosis of NAHI and had ICP monitoring or measurements during the acute illness was entered in the study. Seventeen children with an average age 5.1 months (range 1 to 20 months) were identified. Details of the acute encephalopathy, lowest mean arterial blood pressure (MAP), mean of maximum ICP measured, lowest CPP, and neurodevelopmental outcome at follow up were obtained from the hospital case notes. Seshia's (1994) outcome classification scale was used. The lowest CPP was very significantly related to outcome (P=0.0047, tau=-0.544). Mean of maximum ICP did not correlate with outcome. The lowest MAP was significantly related to outcome (P=0.039). It was concluded that the degree of secondary brain insult from reduced CPP influences outcome.

Fatal Physical Child Abuse in Two Children of a Family

Fatal Physical Child Abuse in Two Children of a Family

One year outcome in mild to moderate head injury: the predictive value of acute injury characteristics related to complaints and return to work

OBJECTIVESTo determine the prognostic value of characteristics of acute injury and duration of post-traumatic amnesia (PTA) for long term outcome in patients with mild to moderate head injury in terms...

024 Neurological and neuropsychological outcome of non-accidental head injury

024 Neurological and neuropsychological outcome of non-accidental head injury

Enhanced enteral nutrition in head injury: effect on the efficacy of nutritional delivery, nitrogen balance, gastric residuals and risk of pneumonia

Background: Early enhanced enteral nutrition (EN) improves clinical outcome in severe head injury. However, poor gastric emptying and certain aspects of intensive care may inhibit delivery of optimum nutrition. Aim: To determine the important causes of interruption to EN and whether attempting early adequate EN could enhance nutritional intake in severe head injury. Methods: Eighty‐two patients were randomized to receive either standard EN or early adequate EN. Data was collected on nutritional intake, causes of interruption to EN, nitrogen balance, volume of gastric residuals and incidence of pneumonia. Results: The median percentage of energy and nitrogen delivered was greater in intervention patients compared to controls over the first week post‐injury ( P < 0.02). During the first 96 h post‐injury, patients received EN during 57% of the potential feeding time. Intervention patients received a higher fluid volume ( P < 0.02) but did not have a higher incidence of pneumonia. Conclusion: Taking into account the importance of initiating and maintaining adequate EN, prioritizing procedures in intensive therapy units could further improve nutritional intake in severe head injury.

Role of coagulopathy in patients with head trauma

Coagulation disorders are a well known complication in patients with head injuries. A prospective study was undertaken to determine the incidence and prognostic value of haemostatic abnormalities in this group of patients. Clotting mechanisms in 105 patients with an isolated head injury were evaluated using platelet count (PC), prothrombin time (PT), activated partial thromboplastin time (APPT), thrombin clotting time (TCT), plasma fibrinogen concentration (Fib), level of fibrin-fibrinogen degradation products (FDP) and increased consumptive coagulopathy grade (ICCG) in the first 24 h after injury. The clinical severity of the head injuries was represented by the post-resuscitation Glasgow coma score (GCS) divided into four coma groups (CG). Test results were compared between two outcome groups of patients: discharged and dead. The incidence of disseminated intravascular coagulation (DIC) by laboratory criteria in the two groups was 12% and 38%, respectively. The differences between mean values of the discharged and dead patients for GCS, APTT, FDP and ICCG were statistically significant ( P < 0.001). There was a very strong correlation between the GCS and values of the FDP, APTT, TCT and ICCG ( P < 0.01). Stepwise logistic regression analysis demonstrated that GCS, FDP level, and ICCG predicted outcome in 84% of cases. Other tests did not provide additional predictive value. We conclude that evaluation of coagulation and fibrinolysis in patients with head injuries is not only important in identifying the occurrence of coagulopathy, but also useful in predicting head injury outcome.

Severe Head Injury Outcome Audit

Neuroanaesthesia Society of Great Britain and Ireland: ABSTRACTS FROM THE ANNUAL MEETING OF THE NEUROANESTHESIA SOCIETY OF GREAT BRITAIN AND IRELAND: PDF Only

Prediction of Outcome in Patients with Missile Craniocerebral Injuries during the Croatian War

The factors assumed to exert an influence on the outcomes of 176 patients who sustained head injuries through projectiles during the Croatian War were evaluated. The type of projectile, wound age, retained foreign bodies, and patient sex and age had no significant influence on outcome. Patients with a Glasgow Coma Scale score of 3 to 5 had 7.3 times higher relative risk of poor outcome than those with a score of 6 to 15. Patients with penetrating injuries (47%), with a projectile's path traversing both hemispheres (45.5%), and with intracranial hematomas (49%) had significantly poorer outcomes than patients without such lesions. Infections were more common in patients with retained foreign bodies in wounds that were older than 48 hours (43%) and in patients with cerebrospinal fluid fistulas (50%). In assessing the outcomes of missile head injuries in wartime, the Glasgow Coma Scale score, type of head wound, site of skull penetration, endocranial projectile path, intracranial hematomas, and complications, especially infectious, represent reliable predictors of outcome.

OUTCOME AFTER MILD HEAD INJURY

Although concern about mild sports head injury has significantly increased in the past decade, few well-controlled studies exist. As such, we are not able to definitively specify the effect of injury biomechanics, severity, frequency, and complications on outcome. Until more definitive research is completed, management of mild head injury will have to be based on clinical judgment rather than empiric fact. Despite present empiric limitations, several tentative conclusions appear appropriate. First, head injury is a relatively frequent occurrence in sports. Second, the overwhelming majority of single, grade 1 injuries have few persisting symptoms, and morbidity in the short-term appears low. Third, multiple injuries (> 3), especially grade 2 or grade 3, may have long-term irreversible consequences. Fourth, as best as we can tell, athletes with apparently equivalent injuries by clinical standards may have different outcomes. Finally, outcome in mild sports head injury must receive increased research attention, and some symmetry and coordination of efforts should be encouraged.

Psychosocial long-term outcome of severe head injury as perceived by patients, relatives, and professionals

We systematically compared information on psychosocial outcome of severe head injury (SHI) gathered from different informants. We evaluated psychosocial outcome in 33 subjects 8.1 +/- 1.4 years after having suffered SHI using data gathered from the patients themselves, caring relatives, and an assessing neurologist. Our data confirm long-lasting negative effects of SHI on psychosocial functioning even in patients with only mild or moderate neurological impairment. Specific problems in social intercourse, stemming from impaired self-control, are regularly reported by the relatives and probably underestimated by the patients and by the doctors. In contrast, we found a remarkable agreement between self-report and professional estimation in other aspects of psychological consequences of SHI such as depressed mood and social withdrawal. Our results challenge the common view that patients having suffered from severe SHI are altogether unreliable informants. However, SHI patients tend to have difficulties in monitoring their specific problems of control of behaviour in social relationships. Therefore information gathered from the caring relatives should always be included when evaluating psychosocial sequels of severe SHI.

Progress in head injury management

Preventable secondary injury remains disturbingly common and can only be reduced by highly organized and integrated services, and careful and continuous monitoring. Continuous non- or relatively non-invasive bedside monitoring of factors closely related to brain metabolism and function is becoming a practical reality. To the extent that the complex changes initiated by traumatic brain injury are ‘processes’ rather than ‘events’ it may become possible for components of injury to be halted or reversed. Pharmacological therapy given early after injury may be able to reduce the harmful events initiated by the injury. Head injury management is multidisciplinary. Improvements in head injury outcome have come about through better organisation of services — efficient retrieval, early investigation and removal of clots, and management in experienced intensive care units. Australian neurosurgeons have played a leading role in defining standards of care, in organizing services and in raising public health issues related to head injury. With the increasing and necessary involvement of other specialists and the greater dependence on technically demanding intensive monitoring and medical management, it is important that neurosurgeons remain at the forefront of the care of patients with head injury and not simply be reduced to managing the surgical complications on request. 86

Associated head injury should not prevent nonoperative management of spleen or liver injury in children.

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

Cognitive Outcomes of Multiple Mild Head Injuries in Children

This study assessed cumulative effects of multiple mild head injuries on cognitive functioning in children. Subjects included 1586 children with one mild head injury, 278 with two, and 51 with three or more head injuries between birth and age 10 years and controls without head injuries matched on gender and total number of injuries. The number of head injuries and injuries not to the head was associated with decreasing performance on measures of intelligence (p < .01), reading (p < .01), and math (p = .02). There was no interaction between case-control status and number of injuries, indicating a similar relationship between cognitive outcomes and number of injuries in head-injured cases and controls. After adjustment for covariates, the relationship between number of injuries and cognitive outcomes became nonsignificant. This study suggests that cognitive deficits associated with multiple mild head injury are due to social and personal factors related to multiple injuries and not to specific damage to the head.

The effect of prehospital anaesthesia on outcome following head injuries

There is differing outcome following differing anaesthetic agents which is unexplained by minor changes in prehospital physiology. Further studies of head injury outcome should include data on the anaesthetic agent used as this may be a confounding variable.

The effect of the adrenocortical axis upon recovery from closed head injury.

Fragments and analogs of the hormone ACTH were previously shown to have beneficial effect on the outcome of head injury, while elevated levels of corticosterone (CS) exacerbate it. In the present study we investigated the role of the hypothalamo-pituitary-adrenal (HPA) axis in the pathophysiology of closed head injury (CHI). CHI was produced in ether-anesthetized rats by a calibrated weight-drop device. After evaluating the functional status according to a set of criteria, at 1 and 24 h, the rats were sacrificed and cortical tissue was removed to determine its water content. CHI was also produced in rats that underwent surgical procedures to remove their adrenal gland (ADEX) or the pituitary (HypoX), thus altering the levels of their circulating HPA hormones. Given after CHI, to rats with intact HPA axis, ACTH reduced edema and improved recovery. ADEX rats (6 days postsurgery) had 10-fold higher levels of plasma ACTH. ADEX rats subjected to CHI showed improved functional outcome (p = 0.008) and reduced edema (p = 0.02). We then produced CHI in three groups of rats: HypoX (15 days postsurgery), HypoX treated with ACTH, and controls. In HypoX rats, CHI resulted in increased mortality (35% vs 0) and edema in the surviving rats, and a slower recovery, as compared with the control. Mortality was prevented, edema slightly reduced, and recovery significantly improved after administration of 1-24-ACTH to HypoX rats with CHI. Our results suggest that ACTH has a cerebroprotective effect on the outcome of CHI.

Outcome of Head Injury in 2298 Patients Treated in a Single Clinic during a 21-Year Period

Between 1968 and 1988, 2298 head-injured patients of all grades of severity were registered in the data bank of a single clinic. The majority of patients were admitted to a community hospital and transferred later to the neurosurgical clinic. The data included mechanism of injury and clinical status at admission, including the level of consciousness according to the Glasgow Coma Score (GCS) before and after resuscitation. After admission, nearly all patients below a score of 8 were intubated and treated with controlled ventilation until the patient awakened, died, or had remained in a steady state for approximately 3 weeks. Assessment of the final outcome was made according to the Glasgow Outcome Scale (GOS) both at discharge and again after the patient's status was stabilized. The results show a stable yearly outcome during the 21 years of recording but a significantly improved good recovery and mortality rate when compared with our previous results. Outcome was significantly correlated to age and type and severity of lesion, as judged by the postresuscitation GCS. The outcome of the 1264 most severely injured, comatose patients (GCS < 9) shows a good recovery rate of 55%, a severely disabled rate of 14%, a vegetative rate of 7%, and a mortality rate of 24%. We attribute these results, which compare favorably with others, to prompt airway control and controlled ventilation in unconscious patients.

Impact of traumatic subarachnoid hemorrhage on outcome in nonpenetrating head injury

The presence of traumatic subarachnoid hemorrhage (tSAH) on admission computerized tomography (CT) scans obtained from patients suffering from severe, nonpenetrating head injury has been shown to be associated with a worse outcome than the injury alone would warrant. However, no previous study has provided a simple means of relating the amount of tSAH, its location, or other abnormal findings on initial head CT scans to outcome in patients with non-penetrating head injury. In this study, admission head CT scans from 252 patients with tSAH, treated at a single institution, were reviewed to ascertain thickness of the tSAH; its location; evidence of mass lesion(s); shift of midline structures (< or = 5 mm vs. > 5 mm); basal cistern effacement; and cortical sulcal effacement. The CT scans were then organized into Grades 1 to 4 with 1 indicating thin tSAH (< or = 5 mm); 2, thick tSAH (> 5 mm); 3, thin tSAH with mass lesion(s); and 4, thick tSAH with mass lesion(s). A stepwise regression analysis of CT features ranked them in descending order of contribution to Glasgow Outcome Scale (GOS) scores at the time of discharge from acute hospitalization as follows: basal cistern effacement, thickness of tSAH, cortical sulcal effacement, presence of mass lesion(s), and location of tSAH. A shift of midline structures was not found to be a significant variable. Further analysis comparing CT grades and admission postresuscitation Glasgow Coma Scale (GCS) scores was highly significant. Patients with lower CT grades had better admission GCS values and discharge GOS scores than those with higher CT grades. From their experience, the authors conclude that their CT grading scale is simple and reliable and relates significantly to outcome at the time of discharge from acute hospitalization.

Traumatic intracerebral lesions without extracerebral haematoma in 218 patients.

218 of the 852 patients in the HIT-2 study of head injury had intracerebral lesions only. They were analysed to get more information on the optimal treatment of these severely injured patients. The initial CT scans were reviewed to exclude patients with extracerebral lesions, and to make a radiological diagnosis of contusion, contusion under a depressed fracture, diffuse axonal injury, or intracerebral haematoma. Deterioration after admission to hospital was seen in 71% of patients. Patients with contusions, and contusions from depressed fractures in particular showed a worse outcome than expected, while patients with diffuse injury had a tendency to improve rather than to deteriorate. Patients with intracerebral haematoma seemed to improve if the mass was evacuated. Nimodipine had an impact only in patients with contusions. Our findings mandate surgical evacuation of contusions and intracerebral haematomas in patients with lesions larger than 20 ml who also have radiological signs of a mass effect. Regardless of an apparently good clinical state in the early phase, intracerebral lesions larger than 50 ml seemed to benefit from surgery as compared to nonsurgical treatment. The findings indicated that a further refinement of diagnostic criteria may enable individually tailored head injury treatment to interfere with most important pathogenic mechanisms. More accurate diagnoses will improve head injury treatment and outcome, and are a prerequisite for making successful pharmaceutical trials of head injury in the future.

Head injury mechanisms and the concept of preventive management: a review and critical synthesis.

Recent advances in head injury research have produced a plethora of useful data coupled with a paucity of conceptual integration across the four ways in which this research is pursued. These research orientations are the epidemiological, biomechanical, basic neuroscientific, and clinicopathologic/therapeutic (including rehabilitation). This overview of the history and current state of the art assumes that biomechanics is the basic science of causation in head injury research and when fully integrated with its counterparts, physiology and pathology, it can serve to overcome our conceptual handicaps. A paradigm integrating biomechanics; into the sequence of preventive, protective, acute therapeutic, and rehabilitative interventions will be described as the concept of preventive management. From this we derive the hypothesized claim that the exact biomechanics and the physiopathologic response at the time of injury (at the macroscopic and microscopic levels) determine the sequence of so-called secondary effects that are conceived as the inexorable delayed manifestations of the primary events and concomitant boundary conditions. Knowledge of these events will enable accurate predictions of the natural history and outcome of head injuries from observations carried out in the early acute phase. Examples to test this claim will be given with particular reference to the two types of traumatic brain injury (TBI) phenomenologically associated with disturbances of consciousness, the onset of which can be either immediate or delayed. The current economics and availability of computational power provide a significant opportunity for the development of selected experimental, physical, and simulated models of head injury on the basis of which the complex neurovascular and nonneural cellular and fluid elements of the nervous system may be accurately modeled. This approach will significantly improve the efficiency and quality of the essential biological and clinical observations and model experiments required to validate the theoretical methods and their predictions.

Outcome of severe head injury is predicted better by electroencephalogram than by clinical examination

Outcome of severe head injury is predicted better by electroencephalogram than by clinical examination