OUTCOME AFTER SEVERE HEAD INJURY
Head injury remains a major cause of disability and death, especially in the young. Of those patients who survive the initial impact and remain in coma for at least 6 hours, approximately 40% die within 6 months. The extent of recovery in the remainder depends on the severity of the injury. Residual disabilities include both mental (impaired intellect, memory and behavioural problems) and physical defects (hemiparesis and dysphasia). Most recovery occurs within the first 6 months after injury, but improvement may continue for years. Physiotherapy and occupational therapy play an important role not only in minimising contractures and improving limb power and function but also in stimulating patient motivation.
Outcome is best categorised with the Glasgow Outcome Scale (GOS - see page 210) which uses dependence to differentiate between intermediate grades. After severe injury, about 40% regain an independent existence and may return to premorbid social and occupational activities. Inevitably some remain severely disabled requiring long term care, but few (<2%) are left in a vegetative state with no awareness or ability to communicate with their environment (see page 210). Prognosis in this group is marginally better than for non-traumatic coma - with about '4 of those vegetative at one month regaining consciousness within one year; of those who regain consciousness, over 2A either subsequently die or remain severely disabled. Of those vegetative at 3 months after the injury, none regain an independent existence.
The duration of coma relates closely to the severity of injury and to the final outcome, but in the early stages after injury the clinician must rely on other features - age, eye opening, verbal and motor responses, pupil response and eye movements.
Patients in coma for > 6 hours Best Glasgow Coma Score > 11 Best Glasgow Coma Score 8-10 Best Glasgow Coma Score < 8 Pupillary response - reacting Pupillary response - non-reacting Age < 20 years Age > 60 years
(from Jennett.B, Teasdale.G, Braakman.R et al. (1979) Neurosurgery 4:283-289)
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