Defining Acute Mild Head Injury in Adults - a Proposal Based

7/29/2019 Defining Acute Mild Head Injury in Adults - a Proposal Based

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JOURNAL OF NEUROTRAUMAVolume 18, Number 7, 2001Mary Ann Liebert, Inc.

Defining Acute Mild Head Injury in Adults: A Proposal Based

on Prognostic Factors, Diagnosis, and Management

FRANCO SERVADEI,1 GRAHAM TEASDALE,2 and GLEN MERRY,3 on behalf of theNEUROTRAUMATOLOGY COMMITTEE OF THE WORLD FEDERATION OF

NEUROSURGICAL SOCIETIES

ABSTRACT

The lack of a common, widely acceptable criterion for the definition of trivial, minor, or mild head

injury has led to confusion and difficulty in comparing findings in published series. This review pro

poses that acute head-injured patients previously described as minor, mild, or trivial are defined as

mild head injury, and that further groups are recognized and classified as low-risk mild head

injury, medium risk mild head injury, or high-risk mild head injury. Low-risk mild injury

patients are those with a Glasgow Coma Score (GCS) of 15 and without a history of loss of con

sciousness, amnesia, vomiting, or diffuse headache. The risk of intracranial hematoma requiring

surgical evacuation is definitively less than 0.1:100. These patients can be sent home with written

recommendations. Medium risk mild injury patients have a GCS of 15 and one or more of the fol

lowing symptoms: loss of consciousness, amnesia, vomiting, or diffuse headache. The risk of in-

tracranial hematoma requiring surgical evacuation is in the range of 13:100. Where there is one

computed tomography (CT) scanner available in an area for 100,000 people or less, a CT scan should

be obtained for such patients. If CT scanning is not so readily available, adults should have a skul

x-ray and, if this shows a fracture, should be moved to the high-risk category and undergo CT

scanning. High-risk mild head injury patients are those with an admission GCS of 14 or 15, with a

skull fracture and/or neurological deficits. The risk of intracranial hematoma requiring surgica

evacuation is in the range 610:100. If a CT scan is available for 500,000 people or less, this exam

ination must be obtained. Patients with one of the following risk factorscoagulopathy, drug or al

cohol consumption, previous neurosurgical procedures, pretrauma epilepsy, or age over 60 years

are included in the high-risk group independent of the clinical presentation.

Key words: mild head injury; traumatic hematomas; computed tomography scan; skull x-ray

1WHO Neurotrauma Collaborating Center, Ospedale Bufalini, Cesena, Italy.2University Department of Neurosurgery, Southern General Hospital, Glasgow, United Kingdom.3D f N U i i f Q l d R l B i b H i l Q l d A li

INTRODUCTION

THE TERM minor head injury was first used in a pa-

per by Rimel et al. (1981). They applied this term to

patients with a Glasgow Coma Score (GCS) of 1315 on

admission, with a loss of consciousness (LOS) of les

than 20 min and who were admitted to hospital for les

than 48 h. Since then many other methods for defining

head injury as minor or mild have been put forwar

(Table 1). The aim of this paper is to propose criteria fo


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classifying a patient with a head injury as mild and, within

this spectrum, to identify those at higher risk of devel-

oping an intracranial complication. The perspective

therefore is neurosurgical and concerned with acute man-

agement, especially the early detection of intracranial

hematomas. Our paper does not concern itself with the

controversy about the extent and basis of any neuropsy-

chological sequelae of mild head injury.

PROCESS

A search was conducted of publications listed in Med-

line from 1978 to 1998 employing the terms minor head

injury and mild head injury. A total of 485 papers

were identified, of which 42 were considered to be rele-

vant to our purpose. Reports limited to children were ex-

cluded, but some papers did not differentiate children

from adults and are therefore included. The initialmethodology is similar to that used by a group of Amer-

ican neurosurgeons on the guidelines for severe head in-

jury management (Bullock et al., 1996), but we have not

classified the papers according to classes of evidence.

EARLY FACTORS RELATED TOINTRACRANIAL COMPLICATIONS OF A

HEAD INJURY

DemographicsType of injury. The frequency of finding an intracra-

i l l i d h (CT) d l

the likelihood of a hematoma requiring evacuation ha

been related to the mechanism of head injury. Such com

plications are significantly more frequent after an assaul

p, 0.01 (Harad and Kerstein, 1992; Jeret et al., 1993

or when pedestrians or cyclists have been struck by mo

tor vehicles,p, 0.0004 (Borkzuck, 1995) andp, 0.00

(Jeret et al., 1993). Harad and Kerstein (1992), in a re

port on a cohort of mild head-injured patients (GCS1315), commented that only those who had been as

saulted or suffered a gunshot wound required an opera

tion. The differences in causation of injury in differen

societies must be considered when comparing report

from different areas of the world, in particular in assess

ing the frequency of occurrence of lesions requiring op

eration.

Age. Increasing age is associated with a higher risk o

intracranial lesions on CT scan (p, 0.01, Lee et al

1995; p, 0.004, Gomez et al., 1996; p, 0.0005Borzuck, 1995, and Jeret et al., 1993). Arienta et al

(1997) reported that age over 60 was a high-risk facto

in patients with minor head injury. Nevertheless, it is un

likely that there is a specific age threshold above which

the risk suddenly increases. Indeed, the underlying pat

tern is more of a gradual progressive increase in in

tracranial complications, which becomes notable an

clinically relevant at around 60 years of age.

Clinical Parameters

Focal neurological deficits.The finding of a focal neurological deficit in an apparently mild head-injured pa

i i f l di f h d l f

SERVADEI ET AL.

TABLE 1. VARIOUS DEFINITIONS OF MINO R T O MILD HEAD INJURY

References Terminology Glasgow Coma Score Clinical data Radiology

Miller et al., 1990; Poon Minor 15 Fully conscious

et al., 1992

Miller et al., 1985; Minor 1314

Miller, 1986 (scale up to 14)Feuerman et al., 1988 Minor 1315 Age . 16 years

Jeret et al., 1993; Lee Mild 15 LOC/amnesia

et al., 1995

Borckzuck, 1995; Dacey Minor to 1315 LOC/amnesia

et al., 1986; Shackford mild

et al., 1992; Stein et

al., 1990

Servadei et al., 1993 Minor to 1315 Brief LOC Skull fractur

low risk

Mohanty et al., 1991 Minor 15 Absence of neurological deficits

Gomez et al., 1996; Mild 1315 With or without LOC

Hsiang et al., 1997

LOC, loss of consciousness.


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intracranial hematoma. Miller et al. (1990) reported, in a

series of patients whose GCS was 15 when first seen at

the hospital but who subsequently developed an intracra-

nial hematoma, that one-third of cases had a focal neuro-

logical deficit on arrival at the hospital. Shackford et al.

(1992), in a multicenter series of 2,766 patients with a GCS

of 1315 with a history of LOC, reported that an abnor-mal neurological examination at the time of admission in-

creased by a factor of three the risk of a subsequent sur-

gical intervention. The finding of an abnormal neurological

examination is more likely with a lower GCS score, par-

ticularly with a GCS of 13 (Gomez et al., 1996). However,

the circumstances of admission to a busy accident and

emergency observation ward do not ensure an accurate or

frequent neurological examination (Brown et al., 1994; In-

gebritsen et al., 1997). Precise guidelines are therefore re-

quired to detect neurological deficits.

Headache and vomiting. These symptoms are common

in patients with mild head injury. They have been re-

ported as often in cases with or without intracranial le-

sions (Hsiang et al., 1997; Miller et al., 1990). In con-

trast, Lee et al. (1995) reported that headache or vomiting

was significantly (p , 0.001) related to the occurrence

of subsequent clinical deterioration in a group of patients

with a GCS of 15 on admission to hospital.

Loss of consciousness/amnesia. The occurrence of

transient LOC or a period of amnesia has been taken a

a conditio sine qua non to differentiate a brain injur

from a scalp bruise or a skull injury. The duration of post

traumatic amnesia (PTA) has been accepted for man

years as an index of the brain injury severity (Dickme

and Levin, 1993). In a large study of fully conscious patients, it was estimated that a history of altered con

sciousness increased the risk of traumatic intracrania

hematoma by a factor of five, that is, from 1/31,370 t

1/6,663 (Teasdale et al., 1990). However the absolute ris

remained quite small. The occurrence and duration o

LOC can be difficult to quantify in practice, as a reliabl

witness is not always available. In one study, the record

ing of questionable LOC/amnesia was not correlate

with a higher incidence of abnormalities on CT scan

(Borczuk, 1995). It is recognized that patients withou

LOC but with a skull fracture may develop an epidurahematoma (Nee et al., 1993). Moreover, in children, a

epidural hematoma can develop in the absence of eithe

LOC or skull fracture (Servadei et al., 1993).

Glasgow Coma Score. Although Rimel et al. (1981

specified a GCS of 1315, other criteria have been used

Table 2 shows the relationship between the GCS on ad

mission, the finding on CT scans, and the subsequen

DEFINING ACUTE MILD HEAD INJURY IN ADULTS

TABLE 2. RELATIONSHIP BETWEEN GLASGOW COMA SCOR E O N ADMISSION AND PRESENCE

OF INTRACRANIAL LESION/NE ED FO R SURGERY IN MINOR HEAD INJURED PATIENTS

Percentage of Percentage o

References Study No. of cases intracranial lesion craniotomy

Cullotta et al., 1996 Retrospective GCS 13 176 28 4.5

GCS 14 796 16 1.6

GCS 15 2398 4 0.4

Stein and Ross, 1990 Retrospective GCS 13 62 40 13

GCS 14 142 22 6

GCS 15 454 13 3.3

Shackford et al., 1992 Prospective GCS 13 200 33 11GCS 14 512 18 3.8

GCS 15 1454 15 3.2

Gomez et al., 1996 Retrospective GCS 13 45 27 17

GCS 14 88 23 6

GCS 15 2351 17 0.3

Borczuk, 1995 Retrospective GCS 13 40 27 7.5

GCS 14 197 18 3.6

GCS 15 1211 6 0.8

Fuermann et al., 1988 Retrospective GCS 13 34 38 5.8

GCS 14 103 19 3.8

GCS 15 236 8 0.8

Hsiang et al., 1997 Prospective GCS 13 45 58 20GCS 14 138 35 5.1

GCS 15 1177 18 2.2


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need for surgical treatment of an intracranial lesion.

These two featuresGCS and CTcan each be an in-

dex of severity of injury since they are related to out-

come (Gomez et al., 1996; Hsinag et al., 1997) as deter-

mined by the Glasgow Outcome Scale (Jennet and Bond,

1975). Patients with a GCS of 13 have been shown, in

two prospective series (Fearnside and McDougall, 1998;Stein and Ross, 1994), to harbor intracranial lesions at a

frequency similar to patients with moderate head injury

defined as GCS of 912. It must be noted that the defi-

nition of an intracranial lesion has varied. As one of the

possible definitions, Shackford et al. (1992) suggested

that an abnormal CT scan was one that showed any in-

tracranial abnormality even if it was not related to injury,

a positive scan was one that demonstrated lesions of

the skull or brain related to injury, and a relevant posi-

tive scan was one that showed acute changes of in-

tracranial contents but excluded skull fracture. Obvi-ously, only the presence of a relevant positive CT scan

was related to outcome.

Skull Fracture

Table 3 summarizes the findings reported in several

papers. Although the topic is controversial, the prevail-

ing finding in reports made from a neurosurgical per-

spective is that the presence of a skull fracture in a pa-

tient with a mild head injury increases the risk of

intracranial lesions by a factor that is both statistically

and clinically highly significant. In one study, in patients

with a comparable level of consciousness, the finding of

a fracture was associated with a 174-fold increased risk

(Teasdale et al., 1990).

In contrast, radiologists opinions, as summarized by

Master et al. (1987), found no difference in the numbe

of intracranial hematomas detected in patients with o

without a skull fracture. It must be pointed out that Mas

ters et al. (1987) included patients of any age (the risk

related to the presence of a skull fracture decreases wit

age, and it is significant only over the age of 10 years

Chan et al., 1990) and with any level of consciousnes(including comatose patients where current policy is to

perform an urgent CT scan) and where adequate data on

follow-up was not provided. Reanalysis of Masters ow

material in the cases matching our definition of mild hea

injury showed that the risk of an intracranial hematom

was 6.4% in the patients with a skull fracture but only

0.6% in those without a fracture.

Indications for Obtaining a ComputedTomography Scan in a Mild Head-Injured Patien

The most crucial decision in a mild head-injured pa

tient is whether or not a CT scan should be performed

A wide range of indications has been put forward:

1. All adult patients with a GCS of 1314; in cases wit

GCS 15, in the presence of a skull fracture (Gomez e

al., 1996; Hsiang et al., 1997; Servadei et al., 1995

2. GCS 13 and 14, and in the case of GCS 15 when a

abnormal mental status is associated (Feuermann e

al., 1988)

3. GCS 15 with skull fracture at any age (Teasdale et al

1990)

4. GCS 13 and 14, and GCS 15 with a history of LOC

(Arienta et al., 1997; Ingebritsen et al., 1996; Stei

and Ross, 1992)

5. Mandatory for a minor head-injured patient with GC

SERVADEI ET AL.

TABLE 3. SOME OF THE PUBLISHED STUDIES AB OUT T HE VALUE OF THE SKULL FRACTUREAS A RISK FACTOR OF INTRACRANIAL HEMATOMAS IN MINOR HEAD-INJURED PATIENTS

Departments Statistical

References Location involved Study analysis Risk factor

Dacey et al., 1986 Virginia Neurosurgery Prospective x2 p , 0.001

Servadei et al., 1988 Italy Neurosurgery, Casualty Prospective x2 p , 0.01

Fuermann et al., 1988 California Neurosurgery Retrospective No statistics No risk factor

Teasdale et al., 1990 U.K. Accident and Retrospective/ Log regression p , 0.0000

Emergency prospective

Neurosurgery

Rosenhorn et al., 1990 Denmark Neurosurgery, Prospective x2 No risk factor

Orthopedics,

Pediatrics

Stein and Ross, 1992 New Jersey Neurosurgery Retrospective No statistics No risk factor

Shackford et al., 1992 Multicenter (U.S.A.) Trauma Centers Prospective Log. regression p , 0.001Gomez et al., 1996 Spain Emergency Department Retrospective Log. regression p , 0.0001

Hsiang et al., 1997 Hong Kong Neurosurgery Prospective x2 p , 0.001


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13; recommended for GCS 14 and 15 (Sahckford et

al., 1992)

6. Any one or more of the following: (a) focal neuro-

logical deficits, (b) basilar skull fracture, (c) scalp in-

jury, and (d) age over 60 years (Borczuk, 1995)

These varying recommendations lead to controversy andclinical confusion. The establishment of a consistent pol-

icy is the main reason for wishing to develop a coherent

risk-based approach to classification. Furthermore, the

application of the categories proposed for investigation

need to be related to the availability of CT scanning.

RECOMMENDATIONS AND DIRECTIONSFOR FUTURE STUDIES

From a neurosurgical perspective, the aim of any pro-tocol for the management of mild head-injured patients

is to identify significant surgical lesions and to evacuate

these before clinical deterioration occurs. Passive, un-

witting conservative management of patients who may

be asymptomatic until clinical deterioration occurs must

be transformed into a deliberate, informed choice be-

tween a surgical or a conservative approach.

Protocols for mild head-injured patients must be ap-

plied universally, not only in neurosurgical centers. The

management of mild head-injured patients in most areas

of the world is not the responsibility of neurosurgeons,and good communication between neurosurgical units

and referral hospitals is essential.

Proposed Definitions

A mild head injury is characterized as having a GCS

of 14 or 15. Patients who, on arrival, have a GCS of 13

are excluded from the group of mild head-injured patients

because their risk of intracranial lesions is similar to that

in the moderately (GCS 912) head-injured patients

(Fearnside and McDougall, 1998; Stein and Ross, 1994).

Patients with a GCS of 14 and 15 seen within 12 h o

injury are defined as having an acute mild head injury

With this population, three levels of risk can be identi

fied (Table 4).

Patients with a GCS of 15 on admission but without

history of LOC, amnesia, vomiting, or diffuse headach

are at low risk (Hsiang et al., 1997; The Study Group1996). The risk of intracranial hematoma requiring sur

gical evacuation is definitively less than 0.1:100.

Patients with a GCS of 15 but with one or more of th

foregoing symptoms are at medium risk (Borczuk, 1995

Stein and Ross, 1990), that is, one or more of LOC, am

nesia, vomiting, or diffuse headache. This includes pa

tients who have recovered from an altered state o

consciousness (so-called concussion). The risk of in

tracranial hematoma requiring surgical evacuation is in

the range of 13:100.

Patients with an admission GCS of 14, or a GCS of 1with a skull fracture and/or neurological deficits are a

high risk (Harad and Kerstein, 1992; Servadei et al

1988; Shackford et al., 1992). The risk of intracrania

hematoma requiring surgical evacuation is in the rang

610:100.

Patients with an admission GCS of 15 with or with

out clinical feedings, absent neurological deficits, an

absent skull fracture, but with one of the following ris

factorscoagulopathy, drug or alcohol consumption

previous neurosurgical procedures, pretrauma epilepsy

or age over 60 yearsare included in the high-riskgroup independent of clinical presentation (Arienta e

al., 1997; Borczuk, 1995; Miller et al., 1986; The Stud

Group, 1996).

Management of Adult Mild Head Injury

Low risk. Patients at low risk can be sent home wit

written recommendations about symptoms that can occu

which would prompt a return to the hospital (Teasdale e

al., 1990; The Study Group, 1996). It must be noted tha

in such patients, the risk of an intracranial posttraumati


TABLE 4. LE VE L O F RIS K FO R INTRACRANIAL HEMATOMAS IN ACUTE MILD INJURED PATIENTS

Definition Glasgow Coma Score Clinical findingsa Neurological deficits Skull fracture Risk factors

Low risk 15 Absent Absent Absent Absent

Medium risk 15 Present Absent Absent Absent

High risk 14 May or not be associated with other clinical or radiological findings.

High risk 15 Present/absent Present Absent Absent

High risk 15 Present/absent Absent Present Absent

High risk 15 Present/absent Absent Absent PresentaOne or more of loss of consciousness, amnesia, vomiting, and diffuse headache.bC l h d l h l i i i l d il d 60


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hematoma is not zero, but the costbenefit ratio is against

any radiological examination.

Medium risk. Medium risk patients have a higher risk

of intracranial hematoma. Where there is one CT scan-

ner available in an area of 100,000 people or less, a CT

scan should be obtained for such patients. Published datashow an incidence of 200350 cases of hospital admis-

sions for mild head injury per 105 inhabitants per year

(WHO Collaborating Centers, 1995), resulting in an av-

erage of one to two examinations per day for patients in

this group. The CT examination must include bone win-

dows; if these show a skull fracture, the patient should

be admitted for 24 h observation since cases of delayed

epidural hematomas have been reported (Riesgo et al.,

1997). If CT scanning is not so readily available, adults

should have a skull x-ray and, if this shows a fracture,

should be moved to the high-risk category and undergoCT scanning.

High risk. In the high-risk group, the risk of an in-

tracranial lesion is 1520% and the risk of a surgically

significant lesion 26% (Table 2). If a CT scan is avail-

able for 500,000 people or less, this examination must be

obtained. If CT scanning is not available, admission and

close clinical observation for at least 48 h is essential in

such patients.

Guidelines for early detection of an intracranial

hematoma, in addition to identifying at-risk patients, mustalso indicate when to perform a CT examination. Clinical

deterioration related to an epidural hematoma occurs

mainly in the first 6 h after injury (Knuckey et al., 1989;

Servadei et al., 1995). In a series of delayed epidural

hematomas, only two out of 31 (6%) appeared in mild

head-injured patients (Poon et al., 1992). The risk of miss-

ing a delayed hematoma is overshadowed by the benefits

of early hematoma detection. A CT scan should be ob-

tained as soon as possible, at most within 4 h of the in-

jury. Most cases of delayed epidural hematomas are iden-

tified on admission as small collections that subsequentlyenlarge (Smith and Miller, 1991). The detection and in-

terpretation of the importance of small collections and

other findings (such as lucent areas within the hematoma

and the presence of air) require expertise, and we advise

that the scan of these patients should be reviewed by a neu-

rosurgeon/neuroradiologist (also with a teleradiology sys-

tem) because transfer may be needed, even if there is not

an indication for immediate operation. In areas where neu-

rosurgery is centralized, early transfer can be life saving

because any subsequent clinical deterioration and/or

hematoma enlargement will occur where the patient canbe treated surgically most expeditiously.

In conclusion, Teasdales (1990) expectation that CT

scanning to all head injured patients in coma or alert with

a skull fracture should achieve early detection of 95% o

intracranial hematoma has been shown to be close to re

ality. Other expectations that mortality for pure

epidural hematoma could be as low as zero (Bricolo and

Pasut, 1984) have also been proved to be feasible (Servadei et al., 1995).

Further substantial reductions in mortality for head

injury, along with spectacular economic savings, ar

less likely to be achieved by increasingly elaborat

medical management in sophisticated institution

than by the prevention of deterioration in patient

who initially appear to be at low risk (Klauber et al

1989) and who are often located outside neurosurgica

units.

ACKNOWLEDGMENTS

We wish to thank Prof. Lawrence F. Marshall, De

partment of Neurosurgery, UCSD, San Diego, for hi

valuable advice in preparing the manuscript.

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Ospedale M. Bufalin

47023 Cesena, Ital

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SERVADEI ET AL.


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