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Romanian Neurosurgery (2010) XVII 4: 421 – 431 421
Management of mild and moderate head injuries in adults
Dana Turliuc, A. Cucu
Universitatea de Medicină şi Farmacie “Gr.T. Popa” Iasi
“Shock is a respite on the road with no return to death.”
(John Collins Warren, 1842 - renowned American surgeon of the 19th century)
Abstract
Introduction: Craniocerebral trauma
(CCT) is a major cause of morbidity and
mortality world wide. In Romania, the
trauma is the forth leading cause of
mortality after vascular, neoplastic and
digestive diseases and its coincidence
continues to increase and this is explained
by the development of transport
infrastructure and by the increasing
number of the motor vehicle and assaults.
CCT consequences lead most of the time
to invalidity, so the patients find it difficult
to integrate in society or to return to their
jobs, and the economic costs are high.
Despite the fact that minor and moderate
CCT appear frequently, their classification
and management remain surprisingly
controversial and pose problems due to the
lack of agreement on definitions, of
universal standardized guidelines, of
insufficient studies and most importantly
the lack of medical logistics and medical
legal environment. Also, the absence of
such guidelines increase the morbidity and
mortality in patients with CCT due to the
lack of information and prompt diagnosis
and have high economic costs because of
diagnostic tests and unnecessary
hospitalization.
Objectives: Demonstrating the need for a
protocol on minor and moderate
management.
Material and methods: The study group
included 91 patients (M/F 66/25) aged
between 8 and 92 years, hospitalized in the
Clinic of Neurosurgery in Iasi in the period
2004-2009.
The patients were clinically evaluated
both at admission (GCS) and at discharge,
imaging (CT) and it was followed up the
etiology of CCT and the present
symptoms.
Keywords: minor CCT, medium CCT,
GOS, protocol, management.
Introduction
Head Injuries (HI) are a major cause of
mortality and morbidity in the world.
In the United States, trauma is the 3rd
cause of death after cerebral and cardiac
vascular diseases and cancer (1); it has a
worrying incidence of 200-400 cases per
100,000 inhabitants, of which Mild Head
Injuries represents a percentage of 80% (2).
In Romania, trauma is the 4th cause of death
after cardiovascular diseases, cancer and
digestive system diseases (3).
Studies conducted in the U.S. have
shown that HI is the leading cause of death
and disability in children and adults aged 1-
44 years, and the moderate HI and severe
HI are associated with an increased risk of
Alzheimer’s disease at 2.3 respectively 4.5
times higher than in healthy population.
Also, men are 2 times more likely than
422 D. Turliuc, A. Cucu Management of mild and moderate head injuries in adults
women to suffer an HI (4). Unfortunately,
the HI hospitalization rate increased from
75% in 100,000 inhabitants in 2002 to
87.9% in 2003 (5). Development of
infrastructure, industry, transport,
increasing the number of vehicles, and
military actions resulted in increasing the
incidence of HI. HI consequences are more
severe in women than in men.
The HI consequences are more severe in
women than in men. The cause of these
differences is not exactly known, but several
factors have been incriminated to be related
to the mechanism of injury, treatment
variability and to different premorbid states
related to gender (6).
Purpose and objectives of HI
management guidelines
Unfortunately, despite that Mild Head
Injuries are common, their classification
and management remain surprisingly
controversial being a constant dispute
subject for physicians. As factors leading to
these controversies, we can mention: the
lack of agreement on definitions, the
absence of standardized and valid universal
guidelines for each country, insufficient
studies in certain areas, lack of prospective
randomized trials, and so forth (7).
Much of the variation in HI
management strategies between the USA,
Canada, Europe and Australia is driven by
local issues such as the availability of
resources and the medico-legal
envirtonment. Thus the USA has higher
rates of CT scanning for Mild Head
Injuries compared to Canada, Europe (8).
Clinical guidelines may reduce
unnecessary tests and hospital admissions
for patients with Mild Head Injury as a
helpful tool and not a substitute for medical
thinking. They were designed for use by
clinicians and neurosurgeons in both HI
management, in major trauma services and
also in regional and local hospitals.
The main objective of these guidelines is
to reduce morbidity and mortality of adult
patients with HI and avoid unnecessary
diagnostic tests and hospital admissions,
especially in patients with Mild Head
Injuries. (9)
Definition of Mild and Moderate Head
Injuries
Summary of closed head injury
classification and outcome (10)
Mild Moderate Severe
Initial GCS 14-15 9-13 3-8
% of total 80 10 10
Abnormal CT scan (%) 10-15 40-50 90
Neurosurgical intervention 1-3 10-15 40-50
Mortality (%) <1 10-15 20-80
Good functional outcome
(%)
>90 50 10-50
A Mild Head Injury is an injury suffered
by a patient with a 14-15 Glasgow Coma
Score (GCS) who arrives to the hospital
after an injury without penetration (with or
without a history of consciousness or
memory loss). For classification of HI, the
Glasgow scale is mostly used and evaluation
should be made both initially and
dinamically. Although intubation and
sedation interferes with GCS, and in some
cases its accuracy is only 75%, this scale still
remains an important universal code in
medicine (11).
Doctors have proposed changes to the
GCS score with an increased sensitivity to
Mild Head Injuries; for example, GCS-
Extended (GCSE) or GCS 15, which
defines the degree of post-traumatic
amnesia (PTA) suffered by the patient. It’s
normal value should be between 0-7. If the
period of amnesia is more than three
Romanian Neurosurgery (2010) XVII 4: 421 – 431 423
months, the score is 0, and if amnesia is
present, the score is 7 (12). GCSE has three
risk categories based on the results of CT
and symptoms:
Low-risk: no symptoms or previous
symptoms of dizziness, headache, vomiting
Intermediate risk: loss of consciousness
or post-traumatic amnesia
High risk: severe headache, persistent
nausea, vomiting ≥ 1 episode. (13)
Typical characteristics of Mild Head
Injuries:
1. direct blow to the head or the
mechanism of acceleration / deceleration
2. transient loss of consciousness or
amnesia *
3. transient changes of vigilance,
behavior or cognitive function
4. rare neurosurgical intervention
5. post concussion symptoms are
common
6. good long-term functional outcome
* Amnesia after a HI is a predictive
factor of intracranial complications.
Retrograde amnesia is a more significant
risk factor than anterograde amnesia. (14)
Risk stratification of HI is based on:
1. GCS on admission and for 2 hours
post-injury
2. the duration of consciousness loss or
amnesia
3. presence or absence of other specified
risk factors
Most important clinical complications
of Mild Head Injuries
Clinicians and patients should be aware
of both the risk of neurosurgical
intervention, and the risk of cognitive-
behavioural sequelae following Mild Head
Injury. They also need to consider that the
absence of visible structural lesion on CT
following Mild Head Injury does not
exclude the possibility significant cognitive-
behavioural sequelae.
Acute life-threatening complications that
require neurosurgical intervention are rare
in Mild Head Injury patients: low risk, 0-
3% and high risk 0,5-6,5% of Mild Head
Injury. (15) Post concussion symptoms are
common in Mild Head Injury patients and
may have significant cognitive-behavioural-
social impacts on both patients and their
families.
Typical post concussion symptoms
include:
- headaches
- dizziness
- fatigue
- memory impairment
- poor concentration
- behavioural changes
- social dysfunction
Up to 50% of patients with Mild Head
Injury may have significant post concussion
symptoms that can persist several weeks.
About 10% of patients with Mild Head
Injuries will have persistent disabling post
concussion symptoms.
424 D. Turliuc, A. Cucu Management of mild and moderate head injuries in adults
The assessment of Mild Head Injuries (1)
Mild Head Injury patients should have a minimum of hourly observations for 4 hours post
injury.
These observations include:
-GCS
-alertness/behavior/cognition
-pupillary reactions
-vital signs
Serial neurological observations should be continued on any Mild Head Injury patients who fail
to clinically improve at four hours post injury or who are found to have structural lesions
requiring hospital admission.
Assessment for post traumatic amnesia (PTA) should be performed on any Mild Head Injury
patients who fail to clinically improve at 4 hours post injury or who are found to have structural
lesions requiring hospital admission.
Skull x-rays are not sufficiently sensitive to be used as a routine screening investigation to
identify significant intracranial lesions.1
CT scanning is the most appropriate investigation for the exclusion of neurosurgically significant
lesions in mild head injured patients.
CT scanning is indicated for those Mild Head Injury patients identified by structured clinical
assessment as being at increased risk of intracranial injury.
If structured clinical assessment indicates the risk of intracranial injury is low, the routine use of
CT scanning is neither clinically beneficial nor cost effective.
The need for CT scanning in Mild Head Injuries (16)
Initial assessment: persistent GCS < 15 at two hours post injury
focal neurological deficit
clinical suspicion of skull fracture *
prolonged loss of consciousness >5 min
prolonged anterograde or retrograde amnesia >30 min
post traumatic seizure
repeated vomiting ≥ 2 occasions
persistent severe headache
known coagulopathy (coagulability disorders, spontaneous
hemorrhage, anticoagulation with warfarin or other
anticoagulants)**
age >65 years (clinical judgment appropriate if no other risk
factors present)
Romanian Neurosurgery (2010) XVII 4: 421 – 431 425
After a period of observation (4
hours post injury):
any deterioration in GCS
persistent abnormal mental status (abnormal alertness,
behaviour or cognition)
any patient who fails to clinically improve
Clinical judgment required if: age >65 years
drug or alcohol ingestion
dangerous mechanism/multi-system trauma
dangerous mechanism of injury production (pedestrian
accident, bicycle accident, ejection from vehicle, violent
physical attack, traumatic fall of 1 m or more than 5 stairs, etc.)
***
*The risk of developing an intracranial hematoma is 12 times higher in patients with skull
fracture radiographically evident than in those without. (16)
**Although patients with coagulopathy are at increased risk of intracranial complications,
recent studies have failed to recognize the importance of this link (2)
***The CHALICE Study 2006 (Children’s Head Injury Algorithm) considers that a fall
of more than 3 meters high is associated with more increased risk for the patient to develope
an intracranial lesion.
Safe discharge of the patients (1)
Patients with HI can be discharged after a period of observation in the hospital, if
they meet the clinical and social criteria:
Clinical criteria: normal mental status and behaviour with clinically improving minor post
concussion symptoms after observation until at least 4 hours post injury
no clinical risk factors indicating the need for CT scanning or normal CT
scan if performed due to risk factors being present
no clinical indicators for prolonged hospital observation such as:
-clinical deterioration
-persistent abnormal GCS or focal neurological deficit
-persistent abnormal mental status or behaviour
-persistent severe post concussion symptoms
-persistent drug or alchohol intoxication
-presence of known coagulopathy (relative criteria)
-presence of multi-system injuries (relative criteria)
-presence of intercurrent medical problems (relative criteria)
-age> 65 years (relative criteria)
Social criteria: responsible person avaible to take patient home
responsible person avaible for home observation
patient able to return easily in case of deterioration
written and verbal discharge advice able to be understood
426 D. Turliuc, A. Cucu Management of mild and moderate head injuries in adults
Discharge advice
criteria:
discharge summary for primary doctor
written and verbal head injury advice given to patient:
-symptoms and signs of acute deterioration
-reasons for seeking urgent medical attention
-typical post concussion symptoms
Initial management of Moderate Head Injuries (GCS 9-13) (1)
Standard care: initial assessment of ABCDEs and resuscitation
early CT scanning to identify neurosurgically correctable focal intracranial
haematomas
period of ED observation
prevention of secondary brain injury by avoiding hypoxaemia (O2 saturation
< 90%) and hypotension (systolic BP <90)
supportive care of ABCDE’s
admit for prolonged hospital observation (24-48 hours) unless rapid clinical
improvement, normal CT scan and absence of other risk factors
early neurosurgical consult if not clinically improving and/or abdnormal CT
scan
routine post traumatic amnesia (PTA) testing
Outcome: approximately 80% of Moderate Head Injuries improve while 20%
deteriorate and required management as per severe head injuries
the majority of patients who suffer Moderate Head Injuries will have some
degree of cognitive-behavioural sequelae and should be considered for
routine follow-up with a brain injury rehabilitation service or a neurologist
HI patient transfer to a neurosurgery service
Patients with Severe Head Injuries (GCS 3-8)
Patients with Moderate Head Injuries
(GCS 9-13), if:
clinical deterioration
abnormal CT scan
normal CT scan but not clinically improving
CT scan unavailable
Patients with Mild Head Injuries
(GCS 14-15), if:
clinical deterioration
abnormal CT scan
normal CT scan but not clinically improving
high risk Mild Head Injury with CT scan unavailable
Romanian Neurosurgery (2010) XVII 4: 421 – 431 427
The transfer of patients with brain
injuries is potentially dangerous if it is
poorly done and, therefore (2), any HI
must be correctly diagnosed so that,
between the onset and neurosurgical
intervention, no more than four hours
should pass. (3)
The purpose of this study was to
demonstrate the necessity of a protocol in
the management of minor and medium
CCT.
Methods and materials
The study was based on a retrospective
study on a group of 91 patients hospitalized
in the Clinic of Neurosurgery in Iasi in the
period January 2005 – December 2009.
The patients selected were aged
between 8 and 92 years (the average age is
52) and the male-female ratio was 66:25
cases. The patients were clinically evaluated
both at admission (GCS) and at discharge,
imaging (CT), and it was followed up the
etiology of CCT, the present symptoms
(headache, intracranial hypertension,
impaired consciousness, and focal
neurological deficit) and the duration of
hospitalization.
The patients who presented other
organs’ involvement and systems, as well as
patients who had preexisting medical
conditions were excluded.
Results and discussions
All the 91 patients were evaluated on
admission by GCS: 35% were minor CCT
(GCS scale 14 and 15) and 65% were
moderate CCT (GCS scale 9-13). The
predominance of moderate CCT was
convenient to us in our analysis to see if
they have not been overrated by the
neurosurgeons (Figure 1).
A percentage of 73% patients of our
group were man (66 cases) and only 25%
women. Also, the literature confirms that
the incidence of CCT in men is twice
higher than in women.
If we take a look at every 10-year age
group, we can observe a uniform
distribution of the cases, except for those
over 89 and under 9 years, which represents
3% of CCT. 19% of the patients with CCT
belong to the 6th decade, followed by the
low percentage of the 7th decade (17%), 5th
(15%) and 2nd (14%). It seems that the
highest incidence is met at patients aged
between 50 and 80 and this represents half
of the total number of TCC. The 14%
percentage of CCT for patients aged 20-29
could be explained by more intensive
activities in this period.
428 D. Turliuc, A. Cucu Management of mild and moderate head injuries in adults
From the distribution of the etiology of
CCT, 41.7% of the patients were
hospitalized for falling on same level,
followed by those with car accidents and
high level falling (approximately 21.9% and
19.7%).
Only 15 patients of a total of 91 came to
the hospital as a consequence to physical
aggression. In current practice, high level
falling is usually associated with moderate
or severe CCT, while falling on same level
is not associated with moderate or severe
CCT.
This mantrap in which the patient’s age,
the symptoms at admission / in dynamic or
CT changes are not taken into account, but
only the mechanism of CCT, makes
moderate CCT to be overrated or even
worse, minor overrated CCT could lead to
risks and adverse consequences for the
patient. The prevalence of CCT caused by
falling on same level (41.7% of CCT) was
convenient in our analysis since this
segment of etiologies of CCT causes the
most confusion.
56% of the patients had MD at
admission and 19% presented headache.
Only 9 patients (10%) displayed signs of
ICH.
After CT scan, it has been discovered at
about a quarter of all patients (24.18%) the
presence of a subdural hematoma
combined with other injuries, at 13.19%
there signs of cerebral concussion and in an
equal percentage of 11% there were patients
with subdural hematoma, with concussion
and cerebral laceration respectively.
Depending on their age, minor and
medium CCT have a similar distribution,
except for some peaks of moderate CCT in
the 2nd and 5th decade.
Distribution of cases according to CT aspect
Romanian Neurosurgery (2010) XVII 4: 421 – 431 429
After the correlation between the
patient’s age and the results of the CT scan,
the differences are statistically significant
(p<0.01). That means that the patients of
the same age, same type of injury have
different CT scan results.
After correlating the etiology with the
symptoms, I have found significant
statistical differences (p<0.05). This reveals
that the etiology of CCT has different
symptoms. Regardless the etiology of
trauma, MD has been prevailingly the main
symptom, followed by headache and
hemiparesis.
After the correlation between the
symptoms and the GCS evaluation, the
differences are statistically significant (p<0,
01). The “error” is given by the fact that the
GCS evaluation does not take into account
the motor or speech deficits which could
also influence the final result.
There have not been significant
statistical differences after the correlations
made between the symptoms and the GOS.
At discharge, the majority of patients with
MD had GOS 1, 2 or 3.
At discharge, it has been discovered that
most patients were evaluated with GOS 2
(44%), followed by patients with GOS 3
(29%) and GOS 1 (23%). Two patients
with moderate CCT died (GOS 5).
At discharge it has been discovered that
most of the patients with minor CCT
(78%) had GOS 1 and GOS 2 (12,
respectively 13 patients). In the case of
moderate CCT, only 15% (9 patients) of
the patients recovered completely (GOS 1),
most of them with GOS 2 (46%) and GOS
3 (36%).
Most patients have GOS 1, 2 and 3
respectively.
430 D. Turliuc, A. Cucu Management of mild and moderate head injuries in adults
Regarding the average length of
hospitalization, I have discovered that the
medium is 14-15 days for minor CCT and
15-42 days for medium CCT. The average
length of hospitalization extremely close as
value raises issues, confirming once again
the consequences of the lack of
management guidelines: morbidity and
mortality of patients with CCT due to the
lack of prompt recognition and diagnosis, of
diagnostic tests and unnecessary
hospitalizations and therefore, high
economic costs.
Conclusions
Based on the results, I have discovered
that minor CCT evolution is influenced by
the precocity of diagnosis, the elimination
of unnecessary time for diagnosis and the
establishment of proper treatment and this
conduct can be set by introducing some
protocols which can be adapted to real
possibilities of each region.
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