Severe Penetrating Head Injury: A Study of Outcomes

306 Severe Penetrating Head Injury: A Study of Outcomes Ross D. Zafonte, DO, Deborah L. Wood, MS, Cynthia L. Harrison-Felix, MS, Scott R. Millis, PhD, Nelson V. Valena, MD ABSTRACT. Zafonte RD, Wood DL, Harrison-Felix CL, Millis SR, Valena NV. Severe penetrating head injury: a study of outcomes. Arch Phys Med Rehabil 2001;82:306 10. Objective: To determine and describe the demographics and functional outcomes of persons who require inpatient rehabilitation for severe penetrating head injury resulting from a gunshot wound to the head. Design: Data were collected prospectively from the time of admission to acute care through discharge from inpatient rehabilitation. Setting: Two sites: an urban, level I, acute care, trauma center and an inpatient rehabilitation hospital with a specialized brain injury unit. Participants: Twenty-seven persons with severe penetrating head injury. Main Outcome Measures: The FIM instrument, the Disability Rating Scale (DRS), and the length of stay (LOS). Results: Demographic data showed our population to be similar to other groups of persons at high risk for violent injury. Eighty-five percent of the subjects were men with a mean age of 34 years. The majority were African American (93%), reflective of our general patient population. Average acute care LOS was 31 days and average rehabilitation LOS was 44 days. Average FIM gain was 40.2 and, on average, DRS scores improved 7.6 points from rehabilitation admission to discharge. All study participants made enough progress to be discharged to private residences. Conclusion: Although the mortality rate is high among patients with penetrating head injury, those who survive to receive inpatient rehabilitation can achieve functional improvement. Key Words: Glasgow Coma Scale; Head injuries; penetrating; Wounds, gunshot; Rehabilitation. 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation VIOLENCE IS AN INCREASING source of mortality, morbidity, and, consequently, disability in the United States. The Centers for Disease Control and Prevention report that in 1997 intentional and unintentional firearm-related injuries claimed the lives of over 32,000 Americans. 1 Gunshot wounds (GSWs) to the head are responsible for a significant From the Rehabilitation Institute of Michigan, Wayne State University, Detroit, MI and the Department of Physical Medicine and Rehabilitation, Pittsburgh, PA (Zafonte, Wood); Craig Hospital, Englewood, CO (Harrison-Felix); Kessler Medical Rehabilitation Research and Education Corp, West Orange, NJ (Millis); and HealthSouth, Houston, TX (Valena). Accepted in revised form June 12, 2000. Supported in part by the National Institute on Disability and Rehabilitation Research, US Department of Education (grant no. H133A970021). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the author(s) is/are associated. Reprint requests to Ross D. Zafonte, DO, University of Pittsburgh, 3471 Fifth Ave, Ste 901, Pittsburgh, PA 15215, e-mail: zafonterd@msx.upmc.edu. 0003-9993/01/8203-6038$35.00/0 doi:10.1053/apmr.2001.18226 portion of the mortality associated with firearm-related injuries. 2 Firearms are now the most common cause of traumatic brain injury (TBI) fatalities in the United States, and the prognosis for survivors of severe penetrating head injury generally is grim. 3,4 Long considered an American phenomenon, penetrating craniocerebral injuries are an escalating problem in other countries as well. 5 Mortality associated with civilian penetrating head injuries has been quite high. 6,7 Studies 8,9 have shown that the majority of persons with GSWs to the head die at the scene, in transport, or shortly after arrival to the emergency department. Among persons with penetrating head injury, with a Glasgow Coma Scale (GCS) score of 3 to 5, the mortality rate appears to exceed 90%. 10 The mortality rate for patients with initial GCS scores between 6 and 8 is as high as 70%. 10 Several studies 9-11 that used the Glasgow Outcome Scale (GOS) reported dismal outcomes for survivors of severe penetrating head injury, but none has assessed specific functional outcome after rehabilitation. Prognosis is felt to be so poor that investigators 3,7 have questioned the use of aggressive medical and surgical management of this population. Additionally, concerns have been raised regarding resource use. The purpose of the present study was to determine and describe the outcome and disposition of severe penetrating head injury survivors who require inpatient rehabilitation care. METHODS We evaluated all TBI patients presenting to a universitybased, level I, trauma center between December 1989 and April 1999. Criteria for study enrollment included: presentation to the emergency department within 24 hours of injury; receipt of acute medical care and inpatient rehabilitation within our system of care; age 16 years or older at the time of injury; and initial GCS of 3 to 8 on arrival to our emergency department. Those persons who had sustained a GSW to the head were eligible. All data were collected prospectively. Demographic data were recorded when the patient was admitted to the acute-care hospital. Discharge disposition from inpatient rehabilitation and length of stay (LOS) were recorded on acute care and rehabilitation discharge. The Disability Rating Scale (DRS) and the FIM were scored on admission to and discharge from inpatient rehabilitation. 12,13 The FIM was analyzed by cognitive and motor subscales. The measures were selected for their ability to detect changes in functional outcome. Both the FIM and DRS were administered and scored by trained personnel. The FIM, a widely used index of rehabilitation outcome, measures the level of assistance an individual requires to perform basic life activities. FIM scores range from 18 to 126; the higher the score, the less assistance is needed by the patient. The DRS (table 1) is a reliable and valid measure of arousal, awareness, cognitive ability for self-care, physical dependence, and gross psychosocial skills that correlate with long-term disability after moderate TBI. DRS scores range from 0 to 30; a lower score indicates a lower level of disability. Because the study was epidemiologic in nature, characterizing our study population and describing various outcome measurements, we examined the collected data primarily by statis-

SEVERE PENETRATING HEAD INJURY, Zafonte 307 Table 1: Disability Rating Scale 12 Eye opening 0 Spontaneous, 2 to pain, 1 to speech, 3 none Communication ability 0 Oriented, 2 inappropriate, 4 none 1 confused, 3 incomprehensible, Motor response 0 Obeying, 2 withdrawing, 4 extending, 1 localizing, 3 flexing, 5 none Feeding, toileting, and grooming 0.0 Complete, 2.0 minimal, 1.0 partial, 3.0 none Level of functioning 0.0 Completely independent, 3.0 moderately depend, 1.0 independent-special 4.0 markedly dependent, environment, 2.0 mildly dependent, 5.0 total dependence Employability 0.0 Not restricted, 2.0 sheltered workshop/noncomp 1.0 selected jobs/competitive, 3.0 not employable tical summary methods (ie, frequencies, descriptives, crosstabulations). Data analysis was performed on a Pentium II computer processor equipped with SPSS for Windows, a version 8.0, a statistical software package. RESULTS Initially, we evaluated 447 persons sustaining a TBI severe enough to require inpatient rehabilitative care. Of those, 43 (9.6%) had a GSW to the head, and 27 patients had an initial GCS score less than or equal to 8. For those patients intubated before initial GCS scoring, a verbal score of 1 was assigned to calculate the total GCS. Data were collected on all 27 study participants who had a severe GSW to the head regardless of the intent (ie, unintentional, self-inflicted, acts of violence) of their injury. Demographic data, functional outcomes, LOS, and final discharge disposition were recorded for all subjects. Demographic data (fig 1) showed our population to be young (mean age, 34.2yr), 85% men, and 93% African American. Analysis of marital status at the time of injury revealed that 56% of the subjects were never married. The majority (80%, Fig. 1. (A) Marital status, race, and (B) age of participants admitted to inpatient rehabilitation.

308 SEVERE PENETRATING HEAD INJURY, Zafonte Fig. 2. Mean LOS for participants requiring inpatient rehabilitation. (o) acute care (mean 30.7d); ( ) inpatient rehabilitation (mean 43.7d). n 20) had no more than a high-school education and 48% (n 13) were unemployed at the time of their injury. Functional outcome data were also obtained. Mean DRS score standard deviation (SD) at admission was 15.1 4.93, whereas mean DRS score at discharge from inpatient rehabilitation was 7.5 3.22, indicating improvement in disability level from severe to moderately severe (table 2). Mean FIM motor score at admission to inpatient rehabilitation was 33.2 19.10, whereas mean FIM motor score at discharge was 64.5 18.75. Mean FIM cognitive score at admission was 11.7 11.70, whereas mean FIM cognitive score at discharge was 20.6 5.21. Both FIM motor and cognitive scores improved from inpatient rehabilitation admission to discharge. Mean SD acute care LOS (fig 2) was 30.70 17.88 days and rehabilitation LOS was 43.74 20.43 days. All study participants were discharged from inpatient rehabilitation to a private residence. Of importance, 16 of the 27 patients (59%) whom we followed had initial GCS scores of 6 or less. Eight of those 16 had initial GCS scores of 5 or less. DRS and FIM scores for this group are shown in table 3. All patients showed improvement from rehabilitation admission to rehabilitation discharge. DISCUSSION Demographic data reported in our study correspond with other studies examining penetrating head injury. The majority of the subjects in our study were young and of minority origin, which reflects our local community. Sosin et al 14 used data from the Multiple Cause-of-Death Public Use Data Tapes (from the National Center for Health Statistics) to review head injury associated deaths (HIADs). Sosin 14 examined HIADs by cause of injury and found that death rates related to firearms were 39% higher for African Americans than for Caucasians, and HIAD rates for African Americans continued to be higher in all age groups through the age of 54 years. They also reported a rate ratio of HIADs caused by firearms of 5.9 to 1 for men to women. 14 Similarly, Harrison-Felix et al 15 noted, in a study of 812 Traumatic Brain Injury Model Systems (TBIMS) participants, that those who incur violence related TBI tend to be men, unmarried, living alone, and less educated at the time of injury. They concluded that socioeconomic factors appear to play a large role in the risk for violent injury. 15 A separate study by Harrison-Felix et al 16 reported an average length of acute care stay of 23 days and an average length of rehabilitation stay of 40 days for TBIMS participants, regardless of cause of injury. We found similar LOSs for our study population. Although this study does not examine the differences in outcome in blunt versus penetrating head injuries, comparisons have been made by others. Of note, Cowen et al 17 found that patients suffering from a blunt injury had lower FIM scores, longer LOS, and increased hospital charges when compared with patients with penetrating injuries. However, no statistically significant differences were observed among all causes. 17 Zafonte et al 18 also concluded that no significant differences exist between survivors of blunt and penetrating violencerelated TBI. Although initially penetrating injuries have a higher mortality rate, the groups have similar outcomes after inpatient rehabilitation. The mortality and morbidity associated with penetrating head injury has decreased with modern neurosurgical care. However, most persons with severe penetrating head injury still die before, during, or shortly after emergency treatment. In a different study 19 examining penetrating head injury, we found that initially 36% of persons sustaining a GSW to the head died before or on admission to our emergency department. Of those admitted, 41% died, most within the first 48 hours of admission. Levy et al 20 also found that persons who survive to be admitted for acute medical care and die tend to do so within the first 2.2 days after admission. Aggressive treatment improves mortality, yet discouraging outcomes have been believed to be inescapable for persons who sustain severe penetrating head injury. 21 Levi et al 21 have reported that the chances of survival for individuals with penetrating head injury whose GCS scores Table 2: DRS Disability Categories Level of Disability Total DRS Score None 0 Mild 1 Partial 2 3 Moderate 4 6 Moderately severe 7 11 Severe 12 16 Extremely severe 17 21 Vegetative state 22 24 Extreme vegetative state 25 29 Death 30

SEVERE PENETRATING HEAD INJURY, Zafonte 309 GCS Table 3: Admission and Discharge Functional Indices in GCS 3, 4, 5 (n 8) DRS FIM Cognitive FIM Motor Admit Discharge Admit Discharge Admit Discharge 3 7.0 5.0 2.0 23.0 28.0 5.0 74.0 89.0 15.0 17.0 7.0 10.0 12.0 19.0 7.0 21.0 59.0 38.0 18.0 12.5 5.5 7.0 17.0 10.0 18.0 23.0 5.0 20.0 13.0 7.0 10.0 16.0 6.0 20.0 53.0 33.0 Average 15.5 9.4 6.1 13.0 20.0 7.0 33.3 56.0 22.8 GCS Admit Discharge Admit Discharge Admit Discharge 4 18.0 7.0 9.0 15.0 16.0 1.0 59.0 90.0 31.0 GCS Admit Discharge Admit Discharge Admit Discharge 5 14.0 9.0 5.0 12.0 19.0 7.0 27.0 53.0 26.0 20.0 10.0 10.0 5.0 22.0 17.0 13.0 51.0 38.0 7.0 5.0 2.0 17.0 17.0 0.0 69.0 88.0 19.0 Average 13.7 8.0 5.7 11.3 19.3 8.0 36.3 64.0 27.7 Abbreviation:, Difference between admission and discharge scores. were 3 or 4 are dismal. Considering the bleak outcome of patients with a GCS of 5 or less, some have questioned early aggressive treatment of these patients. 22 Many researchers, 9,10,23 attempting to identify the critical prognostic factors for persons with penetrating injuries, have focused on mortality and not functional outcome. Among persons with civilian GSWs, those presenting with coma were believed to have a poor prognosis. 3,7,11 Our data appear to show that functional improvement is possible among survivors of severe penetrating injury. Given the fact that most persons with severe penetrating head injury die within the first 48 hours, it appears that extended resource use may not be the paramount issue. Previous studies 7,9,21 have focused on the GOS as a measure of outcome. GOS categories include dead, vegetative state, severe disability, moderate disability, and good outcome. Many studies have dichotomized these rather broad outcome parameters into either good or bad outcomes. Yet, individuals within the severe disability category often display large variations in function and caregiver burden. An individual who is in the severe disability category may be in a skilled nursing care facility and only be able to stick out his tongue on command. Another individual in the same category may be able to perform all their own activities of daily living (ADLs), yet be unable to access public transportation independently. Thus, a need exists for specific outcome assessment for survivors of TBI. Ours is a descriptive study of outcomes among survivors of severe penetrating head injury. The FIM and DRS may be appropriate to assess change from rehabilitation admission to discharge, but more sensitive functional measures are needed to address more subtle changes in levels of functioning over time. 24 Stone et al 25 reported good outcomes among survivors of severe penetrating head injury who received aggressive treatment. They noted a progressive improvement on GOS scores among those individuals who received rehabilitation. Siccardi et al 9 reviewed 314 patients with penetrating head injury and reported that 44 patients underwent surgical intervention and 19 made an adequate recovery. Thirteen of our patients had an initial GCS of 6 or less and 8 had an initial GCS of less than 5. A remarkable finding in our data is that all of the survivors whom we followed through inpatient rehabilitation were discharged to a private residential setting; though all required some levels of care, all avoided institutional placement. Because all patients requiring inpatient rehabilitation at our center were eligible for admission, regardless of payer source, we do not think that a significant selection bias was present. Although discharge to a private residence may not be the gold standard of rehabilitation success, it remains an important finding. Residential discharge often represents lower future costs and a reduced total burden of care. In the present study, we found an average total FIM motor gain of 31.3 from admission (mean, 33.2) to discharge (mean, 64.5). Also FIM cognitive score improved from 8.9 at admission (mean, 11.7) to 20.6 at discharge. This improvement in FIM cognitive score was less than the 10.6 gain reported by Hall et al 26 across all causes of injury, however, our population consisted only of persons with a severe initial injury, whereas the Hall study included persons with mild, moderate, and severe injuries. Millis and Ricker 27 show that though a group of persons with penetrating head injury display disorganization in new learning strategies, they have a relatively intact capacity to store new information. Although our data indicated that survivors of severe penetrating head injury who require inpatient rehabilitation can show surprising improvement on specific functional measures, most persons sustaining a severe penetrating head injury die and many survivors are low level and/or inappropriate for inpatient rehabilitation. Thus, our findings cannot be generalized to all survivors of penetrating head injury. Clearly, additional work is needed to understand the particular characteristics of persons who survive traumatic penetrating head injury to make functional gains. CONCLUSION Mortality rate is high among patients with severe penetrating head injury, yet among those who survive, improvement during inpatient rehabilitation may be quite clinically important. Such functional improvement may allow for disposition to a residential setting, decreasing the associated burden and cost of care to health care delivery systems. 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