Clinical indicators of headinjury severity

• The duration of retrograde amnesia—the period leading up to the injury for which memories have been lost

• The depth of unconsciousness as assessed by the worst score on the Glasgow Coma Scale—a score of 3 indicates absent responses; 15 is normal consciousness

• The duration of coma—this may be difficult to ascertain because of routine sedation and ventilation following severe head injuries

• Neurological evidence of cerebral injury—abnormality on neuroimaging or EEG

• The duration of post-traumatic amnesia—the interval between injury and the return of normal day-to-day memories

The duration of post-traumatic amnesia is the best marker of outcome.(8) This is particularly useful because it can be measured retrospectively quite accurately. Most patients with a post-traumatic amnesia of less than 1 week will be left with little if any disability, while a duration of more than 1 month indicates that there is likely to be enduring and significant disability.

Predictors of a bad outcome after head injury are a previous head injury, older age, APOE e4 status, and alcohol dependence.

There is no universally accepted classification of head injury severity. However, the most widely used grading system is based on the lowest rating of the Glasgow Coma Scale (GCS)(9) following injury.

• Mild: GCS score 13 to 15. Likely to be associated with a loss of consciousness of less than 20 min and a post-traumatic amnesia of less than 24 h. There must be clinical evidence of concussion.

• Moderate: GCS score 9 to 12. Likely to be associated with a loss of consciousness of more than a few minutes but less than 24 h and a post-traumatic amnesia of more than 1 day but less than 1 week.

• Severe: GCS score 3 to 8. Likely to be associated with a loss of consciousness of more than 1 day or a post-traumatic amnesia of more than 1 week.

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