African Journal of Neurological Sciences Pan African Association of Neurological Sciences ISSN: 1015-8618 Vol. 16, Num. 1, 1997

P.L. SEMPLE, N. FISHER-JEFFES

Department of Neurosurgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.

Code Number:NS97001

SUMMARY

At Groote Schuur Hospital head injured patients are managed by the Neurosurgical Department. A retrospective study was undertaken to determine whether the intensive management of head injuries with a low Glasgow Coma Scale (GCS) on admission is justified. One hundred and five patients admitted during 1990 with a GCS of 8/15 or less were grouped on the basis of their GCS following resuscitation. Thirty four patients were admitted with a GCS of 3/15 and fifty two patients were admitted with GCS of 6/15-8/15. The outcome of these patients was then analyzed; the findings suggesting that those patients who have been adequately resuscitated, and have had an intracranical haematoma evacuated, but still present with a GCS 5/15 or less at 6 hours post injury have such a poor prognosis that high tech intensive care may not be justified.

RESUME

Au Groote Schuur Hospital, les traumatises craniens sont pris en charge par le Department de Neurochirurgie. Une crude retrospective a ete entreprise pour savoir si les soins intensifs etaient justifies pour les patients qui, a leur admission, presentaient un faible niveau de "Glasgow Coma Scale" (GCS); 105 patients hospitalises en 1990 avec un GCS egal ou inferiur a 8/15, etaient groupes en se basant sur leur GCS apres reanimation; 34 avaient un GCS de 3/15, 7 de 4/15, 12 de 5/15, et 52 de 6/15 a 8/15. Le devenir de ces patients a ete analyse. Il en resulte que les patients qui, malgre une reanimation correcte et une evacuation de leur haematome intra-cranien, avaient, encore six heures apres le traumatisme, un GCS egal ou inferieur a 5/15, le pronostic etait tellement mauvais que la pratique des soins intensifs de haute technicite ne semblait pas justifiee.

The management of patients with severe head injuries continues to be a major neurosurgical challenge. With improved monitoring and more effective therapeutic modalities the mortality has decreased but the long term morbidity remains very high. ^1,4,9,13 This is even more so in third world countries where there are severe financial and logistical constraints on therapeutic resources. ¹³

Accurate prediction of outcome would enable the medical team to counsel the family, and to make clinical and legal decisions on a sound basis.⁵ Numerous studies have attempted to predict outcome of severe head injuries at an early stage.^{2,3,6,7,8,10,l 1,12,15,16,18,19,21} Possible factors in prediction that appear to be of importance include age, clinical coma scales. computer tomography findings, electrophysiological responses and cerebral blood flow.

At Groote Schuur Hospital all head injuries requiring admission are managed by the neurosurgical department. Our current policy is that all head injuries receive intensive management, despite. the act that with an increasing patient load the available intensive care resources remain limited. .

The aim of this study was to determine whether high cost intensive management of all severe head injured patients is justified in terms of the ultimate outcome.

In 1990, 105 patients admitted to Groote Schuur Hospital following a head injury had Glasgow Coma Scale 20 values of less than 8/15 after resuscitation. All patients received the following treatment - resuscitation on admission; a CT scan of the head; management in an intensive care unit which included incubation ventilation, pC02 control, regular electrolyte assessment and sedation where indicated, and surgery for intracranial haematoma when indicated.

For :the purpose of this study the patients were grouped according to their Glasgow Coma Scale after resuscitation. If resuscitation failed the best Glasgow Coma Scale obtained was used. The groups were GCS of 3/15, 4/15, 5/15, 6/15 and 78/15. The CT scan brain findings and the Glasgow Outcome Scale of the different groups were then analyzed.

The Glasgow Outcome Scale 14 was used to evaluate the outcome at follow-up. The result was described as favourable if there was a moderate disirability or good outcome. An unfavourable outcome was recorded if there was death; a persistent vegetative state or severe disability. The mean period of follow up was 6 months.

The study showed a preponderance of young male trauma patients with 87% of the patients being male, and 65% being under 35 years of age.

The most common aetiology was pedestrian motor vehicle accident (33%); followed by blunt assault (22%); driver or passenger motor vehicle accident (15%) and sharp assault or missile injury (8%) each.

44% of the patients suffered an associated injury, most commonly orthopaedic in nature. 11% of the patients sustained multiple trauma, having 3 or more injuries and 6% had evidence of hypovolaemic shock on admission.

The results of the different GCS groups were then analyzed.

Thirty-four patients had a GCS of 3/l 5 after resuscitation. Thirteen of these patients had head injuries of such severity that they died prior to CT scan being obtained. Of the 19 patients on whom a CT scan was done, 10 showed features in keeping with a diffuse cerebral injury. Four had an isolated intracranial haematoma - either a subdural or extradural haematoma. Three patients had knife tracts and two patients gunshot injuries.

In assessing outcome it was found that the patients with features of diffuse head injuries, gunshot or knife injuries had a 100% mortality. However, patients with an isolated intracranial haematoma,which was surgically managed, had a 50% favourable result ie. good outcome or minor disability as defined by the Glasgow Outcome Scale.

Figure 1: Outcome of patients .who presented with a Glasgow Coma Scale of 3/15

There were 7 patients in the GCS 4/15 group and 5 were investigated. One patient had an angiogram which showed cerebral circulatory arrest and four had a CT scan. Two of these four had features of diffuse cerebral injury and two had acute subdural haematomas. All of the patients in this group had an unfavourable outcome regardless of whether they had diffuse cerebral injury or an isolated intracranial haematoma,

Figure 2: Outcome ofpatients who presented with a Glasgow Coma Scale of 4/15

Twelve patients presented with a GCS of 5/l 5. On Ct scanning six had features of a diffuse cerebral injury, four had a subdural or extradural haematoma and two had contusions. All the patients with features of a diffuse head injury on CT scan had an unfavourable outcome. However, 66% of patients with an isolated intracranial haematoma had a favourable outcome.

Figure 3: Outcome of patients who presented with a Glasgow Coma Scale of 5/15.

Nineteen patients presented with a GCS of 6/15. On CT scanning twelve showed evidence of diffuse cerebral injury; five had an isolated extradural or subdural haematoma; one of a knife tract injury and one was normal. Nine of the twelve patients were found to have a good outcome or minor disability. Patients with isolated intracranial haematomas had a tavourable outcome in 3 out of 5 cases.

Figure 4: Outcome of patients who presented with a Glasgow Coma Scale of 6/15.

There were 33 patients with a GCS of seven or eight, and thirty-two of these had a CT scan. Findings on the CT scan were eleven subdural haematomas; eight contusions; five extradural haematomas; seven diffuse cerebral injuries; and one was normal. Five of 7 patients with features of a diffuse cerebral injury on CT scan either died, remained in a persistent vegetative state or had a severe disability. Seventeen of 21 patients with an isolated intracranial haematoma had a favourable outcome.

Figure 5: Outcome of patients who presented with: a Glasgow Coma Scale of 7-8/15.

The aim of most head injury studies has been to determine if there is a group of patients whose injury is so sever that they will not respond to the therapeutic modalities available.¹⁵ If accurate, early prognosis can be made, the available resources can be used to benefit those patients who are more likely to have a favourable outcome.6 The danger which remains, however, is that a patient who may make a significant recovery does not receive optimal therapy. ^{10, 12, 16,21}

The results of this study suggest that severely head injured patients with a GCS of <5 after resuscitation and with features of diffuse cerebral injury on CT scan have an unfavourable outcome in 100% of cases. If the GCS is >5 there is, however, a favourable outcome in 40%.

In patients with isolated intracranial haematomas there is an expected poorer outcome in patients with a lower GCS. Nevertheless, there is a favourable outcome in a significant percentage of patients in GCS groups namely 50% <5 and 71%> 5.

Thus there appears to be a group of patients whose head injury is so severe and whose prognosis is so poor, that no intensive management may be justified. They are the patients who once fully resuscitated and on being assessed 6 hrs post injury have a GCS <5 and show no isolated intracranial haematoma on CT scan.

Based on the findings of our study and others in the literature a suggested management protocol for severely head injured patients is illustrated in fig 6.

Figure 6: Suggested management protocol of patients with a severe head injury.

The authors recognise that this is a small study. It does, however, indicate that based on GCS readings and CT scan performed after resuscitation, there is a group of patients whose head injury is so severe that they will not benefit from intensive management. Limited, resources could be more utilised to benefit patients who are more likely to have a favourable outcome.

1. Becker D, Miller J, Ward J, Greenberg R, Young H, Saka/as R. 'The outcome from severe head injury with early diagnosis and intensive management. J. Neurosurg 1977; 47:491502

2. Benzer A, Mitterschiffhaler G, Marosi M, Leuf G, Puhringer F, De la Renataire. Prediction of non survival after trauma: Innsbruek Coma Scale. Lancet 1991; 338:977-978.

3. Bowen S, Lawrence B, Marshall F. Outcome in 200 consecutive cases of severe head injury treated in San Diego county: a Prospective analysis. Neurosurgery 1980; 6:237-241

4. Braakman R, Gilpke G, Habbeman T, Maas A, Minderhoud J, Systemic selection of Progngstie features in patients with severe head injury. Neurosurgery 1980; 6:362-369.

5. Choi S, Muizelaar J, Barnes T, Maramou A, Brooks D, Young H. Prediction tree for severely head injured patients. J Neurosurg 1991; 75:251-255.

6. Choi S, Narayan R, Anderson R, Ward D. Enhanced specificity of prognosis in severe head injury. J Neurosurg 1988; 69:381-385.

7. Choi S, Ward J, Becker P. Chart for outcome Prediction in severe head injury. J. Neurosurg 1983; 52:294-297.

8. Diringer M. Early prediction of outcome from Coma. Current Opinion in Neurology and Neurosurgery 1992; 5:826-836.

9. James C Torner. Outcome evaluation in acute neurologjcal injury. Current opinion in Neurology and Neurosurgery 1992; 5:831-839.

10. Jennet B, Bond M. Assesment of outcome after severe brain damage. Lancet 1975; March 1:480-484.

11. Jennet B, Teasdale G, Braakman R, Minderhout J, Knill-Jones R. Predicting outcome in individual patients after severe head injury. Lancet 1976; May 8:968-1034.

12. Levali A, Farina M. Veeehi A, Rossanda M, Marrubini M, Progonosis of severe head injuries. J Neurosurg. 1982; 57:779-783

13. Mass,A, Braakman R,Schouten H, Minderhaut J, van Someren A. Agreement between physicians on assessrnent of outcome of severe head injury. J Neurosurg. 1983; 75: 321-535

18. Rocca B, Martin C, Vivian X, Bidet P, Saint Giles H, Chevalier A. Comparison of four severity scores in patients with head trauma. The Journal of Trauma 1982; 29:299-305.

19.Selladurai B, Jayakumar R, Tan y, Low H.British Journal of Neurosurgery 1992; 6:549-557.

20. Teasdale G, Jennet B. Assessment of Coma and impaired consciousness. Lancet; July13:81-84.

21.Vollmer D, Torner J, Jane J. Age and outcome following trauma coma: Why do older patients fare worse. J Neurosurg 1991; 75:537-549.

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