The Glasgow Coma Scale (GCS) (Table,!) is the cornerstone of the neurological evaluation of the brain-injured patient. It is the best studied of the numerous assessment scales that are available. Although it is fraught with significant interobserver variability, the GCS score has been shown in numerous studies to correlate strongly with outcome. The highest possible total score is 15 and the lowest is 3. Patients with a GCS score of 15 or 14 are often classified as having mild head injury, 13 to 9 is moderate, and 8 to 3 is severe. Patients with a severe head injury (GCS score 3-8) are unable to follow simple commands. The GCS score should be supplemented by an assessment of pupillary response to light and brainstem reflexes, i.e. oculocephalic and oculovestibular responses.
The importance of sequential neurological examinations cannot be overemphasized. When neurological assessment is clouded by sedation or paralysis, intracranial pressure monitoring and repeat CT scanning are invaluable.
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