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 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 stage2,3,6J,8,10,ll,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 fact 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.
PATIENTS AND METHODS
In 1990, 105 patients admitted to Groote Schuur Hospital following a head injury had Glasgow Coma Scale 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 intubation, 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 7- 8/15. 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 disability 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 ormopaeciic 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 3/15 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 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.
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.
Twelve patients presented with a GCS of 5/15. 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 a unfavourable outcome. However, 66% of patients with an isolated intracranial haematoma had a favourable outcome.
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 haernatoma; 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 haeniatomas had a favourable outcome in 3 out of 5 cases.
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 extradura. haematonias, 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.
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.l5 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 or 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 haematornas 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 to severely head injured patients is illustrated in fig 6.
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 favorable outcome.