The outcome from severe with early diagnosis and intensive management

Transcription

1 J Neurosurg 47: , 1977 The outcome from severe with early diagnosis and intensive management head injury DONALD P. BECKER, M.D., J. DOUGLAS MILLER, M.D., PH.D., F.R.C.S., JOHN D. WARD, M.D., RICHARD P. GREENBERG, M.D., HAROLD F. YOUNG, M.D., AND ROMAS SAKALAS, M.D. Division of Neurological Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia o,' In the belief that secondary cerebral compression, hypoxia, and ischemia materially influence the outcome from severe head injury, a standardized protocol was followed in 160 patients, with emphasis on early diagnosis and evacuation of intracranial mass lesions by craniotomy, artificial ventilation, control of increased intracranial pressure, and aggressive medical therapy. Of these patients, 36% made a good recovery, 24% were moderately disabled, 8% were severely disabled, 2% were vegetative, and 30% died. The mortality rate compares favorably with outcomes in similar patients reported from other centers and there has been no increase in the numbers of severely disabled or vegetative patients. It is proposed that vigorous surgical and medical therapy, by preventing or reversing secondary cerebral insults, enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients. KEY WORDS 9 head injury 9 mass lesion 9 intensive care 9 oculocephalic reflex 9 motor response T HE management of patients with severe head injury continues to present neurosurgeons with a major challenge; mortality and morbidity are appallingly high, and detailed neurological and psychosocial follow-up studies reveal that many apparent recoveries are in fact social tragedies?,1~ Although the primary destructive injury to the brain clearly cannot be repaired, the neurosurgical optimist must adopt the stance that if all deleterious secondary processes could be prevented, reversed, or even halted, then some overall improvement in outcome from the injury should be evident. Ideally, the maximum number of patients whose initial injury had caused sufficiently little brain damage to leave a potential for recovery should realize that potential and become indepgndent of help from others. Neurological surgeons have resorted to many different forms of surgical therapy to achieve these aims, ranging from burr-hole exploration to massive decompressive craniotomy, and medical therapy including use of steroids, osmotic agents, controlled ventilation, hypothermia, and barbiturates.l.2,4 6,9,16,1S,21,22,26,31 A major problem in evaluating these measures is that series are seldom randomized for therapy and no therapy, nor are they large enough to demonstrate significant differences in outcome even if so randomized. Results must therefore be compared with earlier results J. Neurosurg. / Volume 47/ October,

2 D. P. Becker, et al. from the same center or with those reported by other centers. It becomes crucial to ensure that groups of patients are comparable with respect to age distribution, neurological status, time seen after injury, and incidence of intracranial mass lesions requiring surgical decompression. Furthermore, a reduction in mortality may be balanced by an equivalent increase in severely disabled patients requiring prolonged and skilled nursing care. The onus, therefore, lies on those reporting results of treating severe head injuries to provide adequate information about the clinical status of the patients and to use a uniform and clear classification of outcome to permit valid comparisons with other reported series. Several years ago, Jennett and his colleagues in Glasgow 14,28 started to document carefully and serially the clinical status of patients with severe head injury and to develop a series of standardized descriptions of consciousness level, neurological signs, and outcome categories. The purpose of this study, which has now expanded to include centers in Holland and the United States, was primarily to determine the feasibility of making an accurate and early prognosis of outcome in individual patients; it has already shown considerable promise in this respect. 12,~5,29 A large volume of uniformly classified information on patients has been amassed; the strikingly similar distribution of outcomes in the different centers in the study has encouraged the statement that, in these centers at least, local variations in therapy, such as administration of glucocorticoids, do not apparently influence outcome. Although such a statement is a reasonable conclusion from the data gathered in this study, we feel that it is important that its implication of therapeutic nihilism be placed in perspective. Thus, it is unlikely that in a consecutive series of patients who have severe primary brain damage, any single drug will dramatically influence outcome. It may be, however, that an entire management regime aimed at prevention of secondary brain damage, which may include glucocorticoids and other agents, will be successful in yielding the largest numbers of good recoveries possible, given the degree of primary brain injury for the patients in the series. Four years ago we instituted a standardized protocol for the management of patients with severe head injury. This was based on the con- cept of earliest possible diagnosis and surgical evacuation of all intracranial mass lesions, and the prevention or detection and treatment of the secondary cerebral insults of hypoxia or brain swelling by artificial ventilation, by continuous monitoring of intracranial pressure (ICP) with treatment of intracranial hypertension by increased ventilation, by cerebrospinal fluid (CSF) drainage, and/or by intravenous mannitol. 1,2 Any cardiopulmonary dysfunction, fluid/electrolyte imbalance, or increase in body temperature was aggressively investigated and treated. The neurological examination was sequentially recorded in a simple but standardized manner with attention to possible signs of brain-stem dysfunction. In addition, all patients have been studied by one or more of the following: ventriculography, angiography, or computerized tomography (CT) scan (in the last 9 months of the investigation). A limited number of patients have also had recordings of multimodality evoked potentials and measurements of cerebral blood flow. Data are now available from 160 patients who either died or have been followed for 3 months or more. In this paper we present the outcome of these patients related to age, neurological status on admission, degree of brain shift, and surgical treatment. To try to determine whether the management protocol has been successful, we contrast our results with several comparable head injury series published recently. We have then reviewed our own protocol to determine whether changes could be made for the better. In separate communications we discuss the results and value of monitoring intracranial pressure '7 and evoked potentials. 7 Clinical Materials and Methods Patient Selection This series consists of 160 patients with severe head injury who were admitted on the Neurosurgical Service of the Medical College of Virginia Hospital from December, 1972, through April, 1976, within 12 hours of injury (usually within 4 hours). The minimum criterion for entry into this study was that patients were unable to obey simple commands. Patients with coma due to alcohol, drug overdose, or epilepsy were excluded. Also excluded from this series were patients 492 J. Neurosurg. / Volume 47/ October, 1977

3 Intensive management of severe head injury with gunshot wounds of the head and those who on arrival at the hospital were already apneic with the combination of bilateral fixed dilated pupils and no motor response to painful stimuli. In the 160 patients neurological status on admission ranged from inability to obey commands to deep coma with loss of pupillary light reaction, reflex eye movements, and the motor response to pain or an abnormal motor, response. Clinical Assessment After initial assessment of injuries, endotracheal intubation, and attention to respiratory function and arterial pressure where necessary, neurological evaluation was carried out. Patients were first approached by verbal stimuli. The term "vocal response" includes all sounds uttered in response to verbal or painful stimuli. Motor responses classified as "purposeful" include obeying verbal commands (no patients on admission) and localizing painful stimuli; "semi-purposeful" responses are synonymous with organized flexor withdrawal; "decorticate" responses indicate abnormal arm flexion accompanied by an element of pronation and wrist flexion; "decerebrate" responses are extensor arm and leg responses to pain with arm pronation and wrist flexion; a flaccid limb with no response is self-explanatory. In classifying our results we have distinguished between "posturing," which includes decerebrate and decorticate responses, and "not posturing," which includes all better responses (purposeful and semi-purposeful). When there was a different response on both sides, for instance, semi-purposeful on the left and decorticate on the right, the patient has been classified according to the best response. In analysis of data we have added the five patients who were flaccid on admission with no motor response to pain to the "posturing" group. The pupillary light reaction was tested and in this communication we differentiate merely those patients in whom the light response was bilaterally absent. This includes patients with dilated and mid-position pupils but does not include patients with pin-point pupils in whom a response could not be seen. In most patients oculocephalic responses have been used to test the integrity of reflex oculomotor function. Patients with concomi- tant cervical spine injury had oculovestibular responses tested. In this paper we classify responses simply as "intact," which includes suppressed (normal responses in patients who regained consciousness later on) and conjugate "doll's eye" responses, or as "impaired," which includes major impairment or failure of unidirectional medial/lateral reflex movement and total absence of response in comatose patients. In this way we do not consider here unilateral oculomotor palsies in the assessment of overall neurological/consciousness status. This basic neurological evaluation was repeated hourly, then at intervals extending throughout the hospital stay, but in this paper we are concerned with the neurological status on admission and its relation to outcome. Diagnostic Measures Immediately after the first neurological evaluation in the emergency room, each patient had a frontal twist-drill hole made and an initial manometric measurement of ventricular pressure taken from the frontal horn (usually the right). After a steady and pulsatile recording of pressure had been made, 8 ml of air was injected into the ventricle and portable anteroposterior and lateral radiographs taken with the patient remaining in the brow-up position. Patients who had 5 mm or more shift of the midline structures were referred for immediate surgical exploration and decompression. Those with less shift or no shift at all and and normal ventricular pressure (0 to 15 mm Hg or 200 mm H20) were transferred to the intensive care unit for observation, continued ICP monitoring, and later study by angiography or CT scanning within 48 hours. Those patients who had elevated ICP (> 15 mm Hg) and little or no midline shift were referred for immediate angiography, or in the last 9 months of this study for CT scanning, to exclude bilateral balancing lesions. Any patient in the intensive care unit who developed rising ICP not immediately explained by changes in blood gases or other easily remediable cause was restudied promptly by arteriography, CT scan, or ventriculography. Surgical Management All patients referred for immediate surgical decompression received intravenous J. Neurosurg. /Volume 47 / October,

4 Intracronial D. P. Becker, et al r-] - Diffuse brain injury (98 patients) [1 - mass lesion (62 patients) t'- O) "6 "6 Z I Age groups in yeors FIG. 1. Age distribution in 160 patients with severe head injury. mannitol (1 gm/kg body weight) on the way to the operating room. A wide craniotomy was carried out in all patients, exposing the frontal and anterior temporal lobe on the appropriate side. After decompression by removal of clot and/or necrotic brain, the bone flap was normally replaced. If not already present, a ventricular catheter or subarachnoid pressure screw was placed for postoperative ICP monitoring in the intensive care unit. Intensive Care Management All patients were initially artifically ventilated on a volume respirator using a high tidal volume (15 ml/kg body weight) and relatively slow rate (10 to 12 min). Small doses of chlorpromazine (25 mg) and/or morphine (1 to 3 mg) were employed to phase patients into the respirator without paralyzing them. Muscle relaxants were only used for studies requiring immobility, such as CT scanning, and for the patients with severe chest injuries or for those who exhibited severe spontaneous hyperventilation. The minute volume was adjusted to maintain arterial pco2 at 25 to 35 mm Hg, and FiO~ (fraction of inspired oxygen) adjusted to hold arterial po2 over 70 mm Hg. All patients received dexamethasone: 10 mg immediately, and 4 mg every 6 hours for at least 3 days. Prophylactic anticonvulsant therapy (phenytoin 100 mg, three times daily) was given to all patients. No attempts were made to induce hypothermia but any increase in body temperature was vigorously treated. Increased intracranial pressure was treated when ICP rose and remained over 40 mm Hg, even if there had been no neurological change, or if any increase in ICP was apparently associated with deterioration in the level of consciousness. Later in this study we initiated treatment at lower levels of ICP? 6 To control ICP, ventilation was increased to bring arterial pco2 down to between 20 and 25 mm Hg, CSF was aspirated or drained from the ventricular catheter against a positive pressure, or intravenous mannitol was given. Evaluation of Outcome Patients were classified into five categories according to the outcome at 3 months or more from the time of injury, based on the scheme of Jennett and Bond. 14 The categories were good recovery, moderate disability, severe disability, vegetative, and dead. The primary distinction between moderate and severe disability is the capacity of the patient in the former category to care for himself/herself. Where it has been necessary to group patients in different categories together, we have taken good recovery and moderate disability together in one group. Diagnostic Groups Summary of Cases Based on the early diagnostic studies, 62 of the 160 patients (39%) had intracranial mass lesions that were treated by craniotomy and surgical decompression. Of these 62 cases, 12 patients had acute epidural hematomas, 26 49,4 J. Neurosurg. / Volume 47/ October, 1977

5 Intensive management of severe head injury TABLE 1 Clinical features on admission of 160 patients with severe head injury Intracranial Diffuse Factor Mass Lesion P Brain Injury Value* No. ~o No. 7o No. of patients 62 mean age (yrs) 33 vocal response 2 3 bilaterally unreactive pupils impaired or absent oculocephalic response hemiparesis decorticate, decerebrate, or flaccid *NS = not significant. Total No. 7o NS NS < < NS < acute subdural hematomas, and 24 mainly intracerebral lesions consisting of frontal and/or temporal lobe contusion usually associated with intracerebral hematoma. The remaining 98 patients had little or no displacement of midline structures, and have been designated as "diffuse brain injury" in this study, purposely avoiding the term "brain-stem injury." Age and Sex Distribution The majority of patients in this series were males (127) and young, the average age being 27 years, with an age range from 4 to 73 years (Fig. 1). The age distribution was heavily skewed, however, with the modal age at 11 to 20 years. The average age of patients with mass lesions was 33 years, higher than that of patients with diffuse injuries (24 years) but the age distributions in the two groups were similar. Clinical Status on Admission The clinical status on admission is shown in Table 1. Only 12 of the 160 patients gave any vocal response to painful stimuli, 23% had bilaterally unreactive pupils, 40% impaired or absent oculocephalic responses, and 46% were at best decorticate, decerebrate, or gave no motor response to pain at all. One-fifth of the patients had evident hemiparesis when first seen. In most respects the patients with mass lesions were clinically worse than those with diffuse brain injury. Outcome from Injury The outcome in this series is shown in Table 2. In the entire series of 160 patients, 36% made a good recovery, 24% were moderately disabled but able to care for themselves, 8% were left severely disabled, and 2% were vegetative requiring institutional TABLE 2 Outcome from injury at 3 months or more* Lesion acute epidural hematoma acute subdural hematoma acute intracerebral mass lesion all intracranial mass lesions diffuse brain injury all head injuries *Graded by the categories of Jennett and Bond.14 Good Recovery Moderate Disability Severe Disability Vegetative Dead No. ~o No. 7o No. 7o No. ~o No. ~o Total J. Neurosurg. / Volume 47/ October,

6 D. P. Becker, et al. TABLE 3 Midline brain shift, neurological signs on admission and the outcome from injury Neurological Signs & Outcome Midline Shift (mm) motor response no posturing 79 (61 7o) 7 (23 7o) posturing 51 (397o) 23 (77~o) oculocephalic response present 86 (66~o) 10 (337o) impaired/absent 44 (34~o) 20 (667o) pupillary light response present 110 (857o) 16 (53 Yo) bilaterally absent 20 (157o) 14 (47~o) outcome good recovery/ moderate disability 83 (64 ~o) 13 (43 7o) severe disability/vegetative 15 (11 ~o) 1 (3 7o) dead 32 (25~o) 16 (537o) care; 30% of the patients died. Patients with intracranial mass lesions had a higher mortality (40%) than patients with diffuse brain injury (23%; x 2= 5.14; p <0.02). Correspondingly, in patients with mass lesions there was a lower proportion of good recoveries and moderately disabled patients (50%) than in those with diffuse brain injury (66%; x 2 = 4.22; p < 0.05). The proportion of patients who remained severely disabled and vegetative was, however, the same in both groups. Within the group of patients with mass lesions, the best outcome was seen in the 12 patients with epidural hematoma, only one of whom died while nine made good recoveries. The worst results were in the 24 patients with intracerebral mass lesions (contusion/hematoma) 13 of whom died with only TABLE 4 Outcome from severe head injury related to age* Medical Age GR/MD SD/Veg. Dead Deathst Total (yrs) No. 7o No. 7o No. ~ No. 7o total *GR = good recovery, MD = moderate disability. Graded by the categories of Jennett and Bond. 14 tdeaths due to systemic medical complications. three good recoveries. The patients with acute subdural hematoma fared a little better, with 11 deaths and only six good recoveries in the 26 patients. Midline Brain Shift Table 3 gives the relationship of midline brain shift to neurological signs on admission and outcome. In the 62 patients with mass lesions, radiographic shift of the midline ranged from 0 (in three patients with bilateral lesions) to 30 mm, with an average shift of 9 mm. Thirty patients had a 10 mm shift or more. By definition all patients with diffuse brain injury had less than 5 mm midline shift, and only 23 of the 98 patients had any measurable midline shift at all. There was no graded relationship between ICP and the degree of brain shift. Abnormal motor responses (decorticate, decerebrate, or nil) and impaired or absent oculocephalic responses and bilateral absence of the pupillary light response were all more common in patients with midline brain shift of 10 mm or more (x 2 = 13.74, 10.94, and 14.25; p < 0.001). The mortality in patients with severe (10 mm or more) midline shift was higher (53%) than in those in whom midline shift was 0 to 9 mm (25%; x ~=9.57; p < 0.01). There was, however, less difference in the numbers of patients who made a satisfactory recovery from injury (x 2 = 4.27; p < 0.05). Thus, although pronounced brain shift implied a significantly worse neurological picture and a higher mortality rate, the number of severely disabled and vegetative patients was not increased and the number of recoveries was still substantial. Outcome Related to Age Mortality increased steadily with age from 22% in the 0 to 20 age group to 57% in the 61 to 80 age group (Table 4). This increase in mortality was due entirely to systemic complications, such as chest infection and myocardial infarction. The death rate from intracranial hypertension remained at 13% to 14% in all age groups. The proportion of patients making a good recovery or remaining moderately disabled did not decrease, however, until the group aged over 60 years. The relatively small influence of age on outcome after head injury in this series must be qualified by emphasizing that the actual 496 J. Neurosurg. / Volume 47/ October, 1977

7 Intensive management of severe head injury number of patients in the older age groups was small. Outcome Related to Neurological Status Abnormal Motor Response. The abnormal motor response category includes decortication, decerebration, and absent response to pain (flaccid). This feature showed a strong association with a poor result in the whole series (Table 5): 68% of patients who were posturing or flaccid on admission died or were left in a vegetative or severely disabled state, while only 19% of those who had a more organized motor response on admission ended in these categories (x 2= 39.96; p < 0.001). This was true also for the subgroup of patients with diffuse brain injury: 76% of those who were posturing on admission had a bad outcome (severely disabled, vegetative, or dead), but only 8% of those who were not posturing fared badly (x 2 = 46.95; p < 0.001). In the patients with intracranial mass lesions, the findings were quite different in that the presence of posturing on admission did not apparently relate to a bad outcome ( = 2.312; not significant). This is an important finding because there was a higher proportion of patients with abnormal motor responses in this group than in the group with diffuse brain injury, and in general the patients with mass lesions had a poorer outcome than those with diffuse injury. It appears, however, that the poorer outcome in this group cannot be simply related to the presence of an abnormal motor response to stimulation. Oculocephalic Responses. There was a strong correlation between the state of the oculocephalic response on admission (Table 5); 73% of those with impaired or absent oculocephalic responses had a bad result, while only 19% of those who had normal oculocephalic responses ended in the categories of dead, vegetative, or severely disabled (X 2 = 47.20; p < 0.001). Unlike the position with the motor response, this association was true both in patients with dif- fuse brain damage and those with intracranial mass lesions (X 2 = and 12.76, respectively; p < 0.001). Bilateral Absent Pupillary Light Responses. There was a strong correlation between bilateral absence of the pupillary light response and a poor outcome from injury (Table 6): 85% of the 34 patients with ab- TABLE 5 Influence of motor and oculocephalic responses on outcome* GR/MD SD/Veg. Dead Responses, Total No. % No. % No. intracranial mass lesions no posturing/ OC intact no posturing/ I OC impaired 4 40 posturing/ OC intact posturing/ OC/impaired total diffuse brain injury no posturing/ OC intact no posturing/ OC impaired posturing/ OC intact posturing/ OC impaired total *oc = oculocephalic responses, GR = good recovery, MD = moderate disability, SD = severe disability. Graded by the categories of Jennett and Bond.~4 sent light responses died or were left severely disabled or vegetative, while only 28% of patients who had at least one pupil with a reaction to light fell into these categories (x 2 = 36.91; p < 0.001). This association was TABLE 6 Influence of bilateral unreactive pupils on outcome* GR/MD SD/Veg. Dead No. % No. ~ No. % Total intracranial mass lesions bilaterally unreactive one/both reactive total diffuse brain injury bilaterally unreactive one/both reactive total *GR = good recovery, MD = moderate disability, SD = severe disability. Graded by the categories of Jennett and Bond. x4 J. Neurosurg. / Volume 47/ October,

8 D. P. Becker, et al. TABLE 7 Influence of the combination of bilateral absent pupillary light response, posturing, and impaired/absent oculocephalic responses on outcome* GR/MD SD/Veg. Dead No. % No. % No. % Total intracranial mass lesions diffuse brain injury total *GR = good recovery, MD = moderate disability, SD = severe disability. Graded by the categories of Jennett and Bond. 14 true both in patients with mass lesions and with diffuse brain injury. Combination of Adverse Signs. The combination of abnormal motor response, impaired or absent oculocephalic responses, and bilateral absence of the pupillary light reaction had, as might be expected, a strongly adverse prognostic significance in that 76% of these patients died (Table 7). However, only 29 or 18% of the total series of patients had this combination of signs, and although none of the 10 patients with diffuse brain injury who had this combination of signs on admission made a good recovery from their injury, three of the 19 patients with mass lesions who had the adverse combination of signs made a good recovery or were only moderately disabled. Comparison of Outcomes With Other Series The protocol described in this paper involves a considerable expenditure of time, personnel, and both physical and financial resources. Some assessment is required to try to determine whether such an intensive regimen that involves artificial ventilation and ICP monitoring in all patients is justified by the results. As stated at the outset, a crucial requirement for valid comparisons of results in different centers is that the groups of patients are comparable, with particular reference to age distribution, range of neurological dysfunction, proportion of patients with intracranial mass lesions, and time from injury at which assessment is made. Outcome categories must also be comparable. Few published series of head injuries contain sufficient information to permit close comparison of figures, but in Table 8 we compare our results with those in five other studies. For purposes of comparison we have omitted the 12 patients who uttered any sound on stimulation when first seen, leaving 148 patients. The other series in the table consist first of two groups of 428 and 172 patients with head injury reported by Jennett and his colleagues from Glasgow, and Groningen and Rotterdam. 15 These two groups of patients show close internal consistency and provide the most information with which other series can be compared; we have used exactly the same outcome classification as was defined by Jennett's group? 4 Of the other three series TABLE 8 Comparison with reported series of severe head injuries Factor Richmond Glasgow 15 Holland 15 Rossanda ~4 Pazzaglia ~~ Pagni 19 No. of patients 148" clinical features average age (yrs) mass lesion (%) decerebrate/flaccid (%) hemiparesis (%) bilateral fixed pupils (%) < 21 impaired/absent oculocephalic responses (%) outcome good recovery/ moderate disability (%) severe disability/ vegetative (%) dead (~o) *For comparison purposes, 12 patients who gave a vocal response to stimuli on admission have been omitted. 498 J. Neurosurg. / Volume 47/ October, 1977

9 Intensive management of severe head injury in Table 8, 223 patients have been taken from a group of 281 patients with head injury reported by Rossanda and her colleagues in Milan? 4 We have omitted from her group the 58 patients who were obeying commands to make her patients comparable with our own and those of Jennett's group. We also compare a series of 282 patients reported by Pazzaglia, et al., 2~ and 1091 comatose patients reported by Pagni. TM The mortality rates (49% to 52%) were strikingly similar in all five series of patients; the mortality rate of 32% in our reduced series of 148 patients is significantly lower than all of these series (x ~ = to 21.30; p < 0.001). The encouraging factor for us has been that this reduction in mortality was not associated with an increase in vegetative and severely disabled patients but was entirely reflected in an increase in the number of those patients who made a good recovery or were only moderately disabled at 3 months or more from injury; thus, the 57% of Richmond patients in these categories is a significantly higher proportion than the 39% of patients the Glasgow series reported in the same categories ( 15.96; p < 0.001) and the 42% of the Dutch series (x 2 = 7.72; p < 0.01). Before jumping to the conclusion that this difference in result can be ascribed to differences in clinical management of head injury, it is essential to examine each series carefully for differences in the patient populations that may contribute to these significant variations in outcome. Jennett's criteria for inclusion in their study are quite clear, stating that patients should have been in a state of coma, defined as inability to obey commands, to give any comprehensible verbal response, or to open the eyes in response to stimulation, for 6 hours or more. is Our reduced group of 148 patients are therefore comparable in the first two respects and although we did not assess eye opening in these patients, the omission of all patients who uttered any sound in response to pain probably covers this area. Our patients were assessed on the admission examination rather than waiting 6 hours, as most of our operated patients had undergone a surgical decompression by this time, but we observed no neurological change between 0 and 6 hours in the unoperated patients. The proportion of patients with intracranial mass lesions was similar in both the Richmond and Glasgow/Dutch patients, and the frequency with which signs of clinical neurological severity were observed was closely comparable. The average age of the patients in our series was 6 to 7 years less than the Glasgow/Dutch group of patients, and since the age distribution of our patients is so heavily skewed, this may be a factor in the difference in results, although we and others 8,12 have not found age to be a major influence on outcome. The series of patients reported by Rossanda, et al.,2~ is of interest because virtually all of the patients with whom we mode comparison were ventilated also, and the same proportions of patients as in our series had intracranial mass lesions requiring surgery and showed decerebrate rigidity or no motor response on admission. Detailed information on the extent and timing of surgical decompression in these patients is not available however. Rossanda's series also had a large number of young patients (21% under 16 years). The series of head injuries recently reported by Pazzaglia, et al., 2~ consisted of 282 patients, 41% of whom had mass lesions. Their outcomes are remarkably similar to those reported by Jennett and his colleagues (Table 8). There was a higher mortality in patients with mass lesions (55%) than in diffuse brain injury (41%), as seen in our series. Pagni's large group of patients TM appears to be rather different from the others we have considered; a greater proportion of patients were decerebrate or flaccid and a larger number had mass lesions requiring surgery. On the other hand, the proportion of patients with impaired or absent reflex eye movements was half that found in both the Richmond and Glasgow/Dutch series. 15 Overgaard, et al., TM reported on the outcome from head injury in 201 patients who were grouped into various categories based on the consciousness level and motor response on admission. The report is important because no patients had steroids, artificial ventilation, or ICP monitoring, but many were treated with barbiturates. This series included 62 patients who were awake or obeying commands on admission, and we have omitted these in making a comparison. The outcomes in the remaining 139 patients can be estimated at 30% good recovery or J. Neurosurg. / Volume 47/ October,

10 D. P. Becker, et al. moderately disabled, 30% severely disabled or vegetative, and 40% mortality. Gutterman and Shenkin, 8 stressing the importance of immediate diagnosis and surgical decompression with careful ventilatory management, have reported excellent results in 52 head-injured patients, all of whom had decerebrate rigidity on admission. The average age of the patients was 30 years but ranged from 3 to 84 years. Of these patients, 56% had mass lesions that were operated on immediately after admission or angiography. The overall results were 44% mortality, 23% severely disabled/vegetative, and 33% good recovery or moderately disabled. The equivalent outcomes in the 56 decerebrate patients in our series, 45% of whom had operated mass lesions, were 61% mortality, 16% severely disabled/vegetative, and 23% good recovery/moderately disabled, which, although poorer, are not significantly different. Discussion This study was not intended primarily as an exercise in prognosis, but as an evaluation of the results of a uniform and aggressive method of treating patients with head injury. However, any consideration of the outcomes of a group of head-injured patients and any comparison with other groups of patients poses immediate questions concerning the influence on outcome of such variables as age, type of intracranial lesion, and the neurological status of the patients at specified intervals from injury. Several authors place great stress on the deleterious influence of advancing age on outcome from head injury ,18,19,23-26 Yet Jennett, et al., 1~ note that in their large series age significantly influenced mortality only below 20 years and over 60 years; decade by decade analysis of the intervening periods showed it to be less important. Carlsson and his colleagues s noted that all of the agerelated increase in mortality in their series of 496 patients was due to systemic medical complications, a finding that exactly parallels our own experience. There appears to be general agreement that patients with intracranial mass lesions have a poorer outcome than those with diffuse brain injury, a'9'19'2~ Also, the mortality rates in reports dealing only with intracranial mass lesions complicating head injury (mainly acute subdural and intracerebral hematoma) 500 are all high, ranging from 45% to 90%. 6,6,9,xl, 16,21,22,26 As shown in this paper, however, and in other series, patients with mass lesions tend to be worse neurologically than those with diffuse brain injury, with a significantly higher percentage of patients showing impairment of pupillary and oculomotor function and abnormal motor responses. We have found, as have others, that loss of the pupillary light response, impairment of reflex oculomotor function, and abnormal motor responses to painful stimulation all carry a markedly worse prognosis for the group of patients in whom these signs are present. 6,8,9,tt,12'lS,~s-2~176 Combinations of these adverse signs are worse still, so that the presence of all three signs was associated with a poor outcome in 90% of cases; on the other hand, this particular combination occurred in less than 20% of the patients, so that this information is of limited prognostic value. Furthermore, this adverse combination did not always signify a poor outcome in patients with mass lesions, since three of 19 such patients made a satisfactory recovery. The capacity for some patients with mass lesions to do well despite adverse clinical signs on admission is also shown by the lack of correlation between posturing and poor outcome in this group of patients, compared with the strong correlation seen in patients with diffuse injury. Similarly, in patients with diffuse injury, any ~ncrease in intracranial pressure further worsens the prognosis, while in those with mass lesions only severely increased ICP (> 40 mm Hg) worsens the outcome. ~7 These differences may be related to the frequency with which abnormal motor responses in patients with mass lesions are secondary to brain herniation rather than due to primary damage. Early evacuation of mass lesions will reverse some of these neurological signs over a period of time, and a more meaningful comparison between patients with mass lesions and those with diffuse injury would be made at various intervals after surgical decompression had been carried out, when mass lesions have been "'converted to diffuse injuries." These data are being collected prospectively at the present time. It would seem inadvisable at any rate to rely on clinical prognostic data at the early stage in patients with mass lesions to justify surgical inaction, as some patients with even the most gloomy combination of signs may do well if decompressive surgery is carried out early J. Neurosurg. / Volume 47/ October, 1977

11 Intensive management of severe head injury and followed by intensive therapy. Jennett la has recently aired the considerable problems caused in terms of cost and resources as well as social suffering produced when heroic treatment of braindamaged patients results in large numbers of severely disabled or vegetative patients. Although the number of such patients is indeed large when viewed as a national problem, our data, Jennett's own figures, and those of several others who have reported results of large numbers of head injuries all indicate that only 10% of any given series of cases will finish severely disabled or vegetative, s,5,15,1e,2~ Furthermore, the fear expressed by Jennett ~s that the more aggressive the treatment of severely injured patients, the greater the percentage of severely disabled survivors has not been substantiated by our own experience, where the reduction in mortality has been entirely reflected by an equivalent increase in the number of patients making a good recovery or being left with moderate disability, while the proportion of poor quality survivors has remained exactly the same as in other series.15. 2o We feel that the present results suggest that our regimen is achieving its stated goal, namely, enabling a greater number of patients, whose initial injury is such as to yield a potential for good recovery, to achieve that potential by preventing or reversing secondary brain insults caused by intracranial mass effects, high intracranial pressure, or by hypoxia, fluid imbalance, or other Systemic problems. It has been stated that patients with intracranial mass lesions can make a satisfactory recovery without decompressive surgery and without artificial ventilation) 7 Although this may be true, it shows only that such patients have the potential for good recovery, and if even one such patient dies or becomes severely disabled as a result of secondary deterioration, this represents a tragic failure of management. The problem then posed for this group of neurosurgeons is no longer whether aggressive surgery on head-injured patients will produce many severely disabled patients, but whether the risks involved in early diagnosis and surgery outweigh the expected benefits in some circumstances. This question hinges on the important issue of clinical observation of the head-injured patients for "signs of deterioration." If the patient is speaking, J. Neurosurg. / Volume 47 / October, 1977 obeying commands, or localizing painful stimuli, it may be reasonable to risk some clinical deterioration by ordering a study, such as a CT scan or angiography, which requires transportation and takes a little time to perform, and which may require sedation or anesthesia. When the patient is already decorticate or decerebrate, however, further clinical deterioration will result in complete loss of the motor response, usually accompanied by pupillary dilatation and apnea, so that no time can be lost in obtaining an intracranial study. We continue to believe that in these special circumstances twist-drill ventriculography is justifiable because it provides rapid information about both brain shift and ICP. On this basis and because of our early experience with CT scanning, we have now modified our initial treatment protocol. Patients who have purposeful limb movements or better responses on admission will proceed directly to CT scan, under anesthesia if this is required for results of good quality. Those patients with an abnormal motor response (decorticate, decerebrate, or flaccid) will continue to be evaluated first in the emergency room by twist-drill ventriculography, and be sent for surgery, CT scanning, or to the intensive care unit depending on the level of the intraventricular pressure and the degree of midline brain shift. If rapid, immediately accessible CT scanning were available, this could become the emergency procedure of choice for all patients. We emphasize early surgical approach to decompression in acute head injury which should always be by generous craniotomy, and not by multiple burr holes. We believe that artificial ventilation of severely headinjured patients carries more advantages than risks, and that any upset in cardiopulmonary function, fluid and electrolyte balance, or body temperature must be vigorously investigated and promptly corrected. Underlying this regimen is our belief that secondary insults do have an important adverse influence on the outcome from head injury and that, if these insults can be prevented or reversed, patients who would have died can make a useful recovery. References 1. Becker DP, Vries JK: The alleviation of increased intracranial pressure by the chronic administration of osmotic agents, in Brock M, Dietz H (eds): Intracranial Pressure. 501

12 D. P. Becker, et al. Berlin/Heidelberg/New York: Springer- Verlag, 1972, pp Becker DP, Vries JK, Young HF, et al: Controlled cerebral perfusion pressure and ventilation in human mechanical brain injury: prevention of progressive brain swelling, in Lundberg N, Pont6n U, Brock M (eds): Intracranial Pressure II. Berlin/Heidelberg/ New York: Springer-Verlag, pp , Carlsson C-A, von Essen C, L0fgren J: Factors affecting the clinical course of patients with severe head trauma. Part 1: Influence of biological factors. Part 2: Significance of posttraumatic coma. J Neurosurg 29: , Clark K, Nash TM, Hutchison GC: The failure of circumferential craniotomy in acute traumatic cerebral swelling. J Neorosorg 29: l, Cooper PR, Rovit RL, Ransohoff J: Hemicraniectomy in the treatment of acute subdural hematoma: a re-appraisal. Surg Neurol 5:25-28, Fell DA, Fitzgerald S, Moiel RH, et al: Acute subdural hematomas. Review of 144 cases. J Neurosurg 42:37-42, Greenberg RP, Becker DP, Miller JD, et al: Evaluation of brain fuoction in severe human head trauma with multimodality evoked potentials. Part 2: Localization of brain dysfunction and correlation with posttraumatic neurological conditions. J Neurosurg 47: , Gutterman P, Shenkin HA: Prognostic features in recovery from traumatic decerebration. J Neurosurg 32: , Harris P: Acute traumatic subdural hematomas: results of the neurosurgical care. Head Injuries. Proceedings of an International Symposium. Edinburgh: Churchill-Livingstone, 1971, pp Heiskanen O, Sipponen P: Prognosis of severe brain injury. Acta Neorol Stand 46: , Jamieson KG, Yelland JDN: Surgically treated traumatic subdural hematomas. J Neurosurg 37: , Jennett B: Prognosis after head injury, in Vinken P J, Bruyn CW (eds): Haodbook of Clinical Neurology, Volume 24. Injuries of the Brain and Skull, Part I1. North Holland: Amsterdam, 1976, pp Jennett B: Resource allocation for the severely brain damaged. Arch Neurol 33: , 1976 (Editorial) 14. Jennett B, Bond M: Assessment of outcome after severe brain damage. A practical scale. Laocet 1: , Jennett B, Teasdale G, Braakman R, et al: Predicting outcome in individual patients after head injury. Lancet 1: , Kjellberg RN, Prieto A Jr: Bifrontal decompressive craniotomy for massive cerebral edema. J Neurosurg 34: , Miller JD, Becker DP, Ward JD, et al: Significance of intracranial hypertension in severe head injury. J Neurosurg 47: , Overgaard J, Christensen S, Hvid-Hansen O, et al: Prognosis after head injury based on early clinical examination. Laocet 2: , Pagni CA: The prognosis of head injured patients in a state of coma with decerebrated posture. J Neorol Sci 17: , Pazzaglia P, Frank G, Frank F, et al: Clinical course and prognosis of acute post-traumatic coma. J Neurol Neurosurg Psychiatry 38: , RansohoffJ, Benjamin MV, Gage EL Jr, et al: Hemicraniectomy in the management of acute subdural hematoma. J Neorosurg 34:70-76, Richards T, Huff J: Factors affecting survival from acute subdural hematoma. Surgery 75: , Robertson RCL, Pollard C Jr: Decerebrate state in children and adolescents. J Neurosurg 12:13-17, Rossanda M, Selenati A, Villa C, et al: Role of automatic ventilation in treatment of severe head injuries. J Neurol Sci 17: , Stewart WA, Litten SP, Sheehe PR: A progoostic model for brain stem injury. Surg Neurul 1: , Tallala A, Morin MA: Acute traumatic subdural hematoma: a review of one hundred consecutive cases. J Trauma 11: , Teasdale G, Galbraith S, Jennett B: Traumatic intracranial hematomas: detection, prognosis and management. J Neurosurg Psychiatry 39:918, 1976 (Proceedings) 28. Teasdale G, Jennett B: Assessment of coma and impaired consciousness. A practical scale. Laocet 2:81-83, Teasdale G, Jennett B: Assessment and prognosis of coma after head injury. Acta Neurochir 34:45-55, Vapalahti M, Troupp H: Prognosis for patients with severe brain injuries. Br Med J 3: , Venes JL, Collins WF: Bifronta[ decompressive craniectomy in the management of head trauma. J Neurosorg 42: , 1975 This work was supported by NIH Grant 1 P50 NS Address reprint requests to: Donald P. Becker, M.D., Division of Neurosurgery, P.O. Box 758, Virginia Commonwealth University, Medical College of Virginia, Richmond, Virginia J. Neurosurg. / Volume 47 / October, 1977