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Defining the Limits of Survivorship after Very Severe Head Injury

Quigley, Matthew R. MD; Vidovich, Danko MD; Cantella, Diane RN; Wilberger, Jack E. MD; Maroon, Joseph C. MD; Diamond, Daniel MD

The Journal of Trauma: Injury, Infection, and Critical Care: January 1997 - Volume 42 - Issue 1 - p 7-10

Background  Reliable prediction of outcome after head injury is a daunting task. Although previous reports have highlighted the difficulties of determining outcome in the cohort of severe head injury Glasgow Coma Scale (GCS) score < or = to 8), we wondered within the very severely injured population (GCS score 3-5) if a simple combination of clinical parameters may be predictive of poor outcome.

Methods  All patients admitted to a Level 1 trauma center with a GCS score of 3 to 5 from 1986 to 1991 inclusive (380 patients) were retrospectively reviewed and outcome a minimum of 6 months after injury was determined by chart review or telephone.

Result  Follow-up was accomplished in all but five patients (1.3%). Functional survival (nonvegetative) was correlated to admission GCS score, pupillary abnormalities, and age. As anticipated, overall functional survival was poor (12.5%), and even worse among those evidencing pupillary abnormalities (6.6%). Interestingly, there was an absence of survivors in the advanced age decades, with the oldest functional survivor of any GCS increasing in a stepwise fashion with increasing coma score. This translated into the oldest survivor of a GCS score of 3 being in their chronologic 30s, a score of 4 in their 40s, and a score of 5 in their 50s. Among patients older than these age decades, that is beyond this simple age/GCS cut-off (32.8% of cohort), there were no functional survivors (95% confidence interval 0, 2.4).

Conclusions  Within the population of very severely head injured patients (GCS score 3-5), the simple combination of age and admission GCS score appears to predict accurately nonfunctional outcome in almost one third of patients. If confirmed at other centers, this may have wide-ranging implications regarding counseling of families, utilization of resources, and the design of head injury studies.

From the Division of Neurosurgery, Allegheny General Hospital, Pittsburgh, Pennsylvania and Medical College of Pennsylvania/Hahnemann University, Philadelphia, Pennsylvania, and the Department of Surgery (D.D.), University of Tennessee, Knoxville, Tennessee.

This work was presented at the 44th Annual Meeting of the Congress of Neurological Surgeons, Chicago, Illinois, October 1-6, 1994.

Address for reprints: Matthew R. Quigley, MD, 420 East North Avenue, Pittsburgh, PA 15212.

© Williams & Wilkins 1997. All Rights Reserved.