Journal of Neurology, Neurosurgery, and Psychiatry 1984;47:260-268

Late outcome of very severe blunt head trauma: a

10-15 year second follow-upINGER VIBEKE THOMSEN

From Hospital ofPhysical Medicine, Hornbaek and Department ofNeurology, Rigshospitalet, UniversityHospital, Copenhagen, Denmark

SUMMARY Forty patients with very severe blunt head trauma (post-traumatic amnesia , 1month) were initially examined at an average of 4 5 months after the injury. The patients werevisited in their homes 2 5 years and 10-15 years after the accident and questionnaires werepresented to patients, relatives and/or staff. Though physical impairment, dysarthria and defectsof memory remained severe in many cases, the psychosocial sequelae presented the most seriousproblems. Permanent changes in personality and emotion were reported in two thirds and wereespecially frequent among the youngest patients. The worse overall outcome was seen in caseswith severe brainstem involvement or anterior lesions or both. In spite of the great frequency ofdeficits long-term improvement of functional state was common and several regained at leastsome work capacity.

The majority of patients surviving very severe headtrauma are young people. A few may have a rathersatisfactory recovery, but most face disability forlife.

Investigations on late outcome are few in numberand vary in populations studied, criteria of outcome,and interval between trauma and assessment.'-3 In1967 London4 drew attention to the increasingnumber of severely disabled survivors of headinjury. He emphasised the distressing effects ofsevere cerebral damage on the personality and theheavy burden imposed upon the family. Fahy et al2found in a 6 year follow-up of a group of patientsthat few escaped permanent sequelae: recovery ofmotor dysfunction was generally good and eventualneurological residua were more easily tolerated bypatients and relatives than psychiatric impairment,including dementia. At a follow-up 1 to 6 years afterdischarge from hospital, Najenson et a13 describedimprovement in motor deficits, in functional stateand, to a lesser extent, in intellectual functions.

Results of quantitative assessment5 as well asinformation based upon repeated structured inter-views of close relatives during the first posttraumatic

Address for reprint requests: Dr IV Thomsen, Department of Neurology,Rigshospitalet, 2100 Copenhagen 0, Denmark.

Received 30 July 1982 and in revised form 26 February 1983Accepted 14 May 1983

year6 7correspond with clinical findings. Daily livingis primarily affected by impairment of personalityand intellect and, to a lesser extent, by physicalincapacity and disorders of communication. Emo-tional changes and disturbed behaviour are oftenserious problems to the relatives.

In the author's8 follow-up study of patients withsevere head trauma the greater part suffered fromloss of social contact and nearly all relatives com-plained of changes in personality and behaviour. Atsecond follow-up (to be reported in this paper) theauthor aims to provide data on the late psychosocialoutcome.

Method

PatientsForty patients from an original group of 50*: 28 males and12 females with severe blunt head trauma constituted thesample. The males were aged 15-44 years (mean 21.5)when injured, the females 15-44 years (mean 27-3).Seventeen were more aged than 21 years (mean 29.7) and23 were 15-21 years (mean 18-5). Three were injured byfalls, and 37 were victims of road traffic accidents. Half themen and nine women were involved in car accidents,nearly all the latter as front seat passengers. All wereunconscious at the scene of disaster and by admission tohospital and remained so for days or weeks. The post-

*Of the remaining 10, four had open brain injuries, three had notbeen visited, and three had died. They were all found dead in theirapartments 4, 11 and 12 years respectively after the trauma.

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Late outcome of very severe blunt head trauma: a 10-15 year second follow-up

Table 1 Types oflesions and length ofPTA

Types of lesions PTA Total no.patients

1-2 months 2-3 months > 3 months

I.Closed head injury 1 3 5 9II.Closed head injury with signs of brainstem

damage 1 1 13 15II.Closed head injury with verified focal lesion 1 6 9 16

traumatic amnesia (PTA) was more than 3 months in 27and no one had a PTA of less than one month (table 1).The sample is thus of very severely injured patients. Therewas no difference in PTA in the two age groups, that is,above or below 21 years (Mann Whitney rang sum test).The types of lesions are described in table 1. Nineteenpatients had skull fractures. Fifteen had signs of brainsteminvolvement (type II), and 16 patients with type III lesions(12 left and four right) had neurosurgical operations forremoval of a haematoma except for two with depressedfractures. This type of lesion was most common among theyoung.The patients came from all over Denmark and the

majority were labourers or clerks. There were no grosslypsychosocially maladjusted or obvious alcoholics in theseries.

ProcedureThe patients were initially examined by the author at anaverage of 4 5 months after the trauma, and were treatedfor months or years for their neuropsychological dysfunc-tions, especially those of communication. A follow-upexamination8 took place at least one year (on average 2 5years) after the injury. The patients were readmitted tohospital and seen by a neurologist, a clinical psychologistand by the author, who also paid visits to the patients'homes, where a close relative was asked questions aboutthe patient's physical and mental state, behaviour andself-care ability.Between 10 and 15 years after the injury another visit by

the author took place. An expanded questionnaire waspresented to a relative (if possible the same one as before)or the staff at nursing homes, hospitals and/or work-shops.The patients were interviewed by a similar, but not identi-cal questionnaire. When the two statements did not agree,the relative's or staffs answers were preferred. In somecases, in which there was no longer a close relative, onlythe patient's answers could be obtained. The patients werenot admitted to hospital and assessment of cognitive func-tions did not take place. The results at the second follow-up are thus based on the information the author received inthe homes.

Results

By means of these procedures, continuing distur-bances in the following areas were examined (A)medical and demographic, (B) neuropsychological,and (C) psychosocial.

A. Medical and demographic sequelae

Place ofliving The place of living at the time of thefirst and second follow-up (2.5 and 10-15 yearsrespectively) is shown in table 2.The greatest change during the interval was the

number of single patients leaving their homes as achild. A few did so voluntarily, the remainingbecause they lost their father or mother. Nine weremarried at the first follow-up (one lived in a nursinghome). At the second follow-up seven (two men andfive women) had been divorced. They all had chil-dren. The two patients who remained married hadno children. In the years between the examinationssix had married, but two had divorced again. Twowere cohabiting. At the second follow-up three werein nursing homes and one patient had spent the pasteight years in an acute psychiatric ward.

Physical sequelae Motor impairment was initiallypresent in all (table 3). At the first follow-up 10 hadrecovered, six from hemiparesis, one fromhemiparesis and mild cerebellar symptoms, andthree from bilateral spasticity. Of the remaindernone was bedridden, but 12 had severe and fivemoderate symptoms. Cerebellar dysfunction wasfrequent, also among those with mild deficits. Thephysical status was unchanged at the secondfollow-up, except in one case in which cerebellarsigns had become pronounced. Seven were confinedto wheelchairs and six had severe ataxia and/or poorbalance. Eleven had lesions with brainstem

Table 2 Place ofliving at first and second follow-up

2-5 years 10-15 years

Alone 2 17Alone with child 1 2With parent(s) 24 9With spouse or partner 8 8In hospital or nursing home 5 4

Table 3 Motor impairment

L. examination 2-5 years 10-15 years

Severe 18 12 13Moderate 7 5 4Mild 15 13 13No symptoms 0 10 10

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involvement (type II). With reference to age, seven

were 21 years or less, when injured, and six were

more than 21.At the first follow-up one patient had recovered

from a IInd two patients from a IIIrd, and one from a

VIth cranial nerve lesion. Severe visual impairmentremained in four cases. Two had a IInd + a IIOnerve lesion, one a IInd + a IVth, and one a IIIrdcranial nerve lesion with bilateral ptosis. All hadsevere visual problems at the second follow-up.Hemianopia remained permanent in a further fourpatients and so did anosmia in two patients with noskull fractures.

Late epilepsy was reported in nine (23%). Thefirst attack occurred during the first year in fourcases, in the remaining up to 11 years after thetrauma. Seven had verified focal lesions (type III).

Psychiatric sequelae The frequency of post-traumatic psychoses can be seen in table 4. Earlyonset occurred in two cases. A 25-year-old man witha type I lesion including bilateral frontotemporaldamage (permanent EEG findings) remained in apsychiatric hospital for five years. He presented nopsychotic symptoms 12 years after the injury andwas able to live alone. A 17-year-old female patientwith multiple fractures of the skull, especially in theanterior base and in the frontoorbital regions,became a schizophreniform psychotic in relation tosurgical correction of the legs and remained so forseveral weeks. Her parents were killed in the acci-dent and the patient spent many years in a nursinghome. She had loss of sexual inhibition. At the sec-ond follow-up she was cohabiting with a much olderman. It was not possible to establish a genuine emo-tional contact with her.

Thomsen

Late onset occurred in six cases. Two patients hadpermanent problems. One, a young woman withfractures in the frontal regions and a PTA of 5months had a total loss of sexual inhibition andoccasional fits of rage during which she attacked thestaff in the psychiatric nursing home. The other, aman aged 22 years when injured had a type II lesionand a PTA of 4 months. He was referred to apsychiatric hospital two years after the traumabecause of aggressive behaviour and fear of suicideattempts. He was an orphan and had no relatives. Atthe second follow-up he had stayed eight years in anacute psychiatric ward without any treatment at all.His severe left hemiparesis, severe dysarthria anddysphonia (trauma to larynx) remained. Wheninterviewed the patient spontaneously said, "I amkept under lock and key and forgotten".

Eight patients (20%) thus had posttraumaticpsychoses. Five had signs of frontal and/or temporaldamage. Six were below the age of 21 when injured.None of the patients had premorbidly been admittedto psychiatric departments.

Dependance At the first follow-up informationfrom relatives as well as clinical observation indi-cated that 24 patients were dependant. Nine neededhelp with washing, dressing and eating and theremaining could not be left alone. At the secondfollow-up half the patients, including one with initialtotal dependance, were able to take care of them-selves. Of the 12 patients who remained dependant,three were in nursing homes and one in a psychiatrichospital. All had difficulties in self-care as had a

further eight patients of whom seven lived with theirfamilies and one in sheltered housing. Two had no

motor deficits and two had mild motor symptoms.

Table 4 Post-traumatic psychoses

Sex Age at Type of Total PTA Onset Duration Status at HI.trauma lesion months follow-up(yr)

m 25 I bilat. 4 3m. 5y. lives alone, no problemsfr.temp.*

f 17 I bilat. 4 Sm. weeks cohabiting, no sexual inhibition, nofr. orbit.t genuine contact can be established

f 16 II frontalt 5 ly. permanent in psych. nursing home, iio sexualinhibition, fits of rage

m 22 II 4 2y. permanent in acute psych. ward,total loss of social contact

m 20 III ltemp. 6-5 ly. weeks in nursing home, severe emotional3y. regression6y.

m 18 II 4 6y. weeks lives alone, loss of social contact9y.

m 19 III l.hemisph. 4-5 2y. weeks lives with parents, has knocked downhis father three times

m- 18 II bilat. 8 Sy. weeks lives with parents, fits of ragefr. temp.*

*repeated EEG findingstfractures of skull

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Late outcome of very severe blunt head trauma: a 10-15 year second follow-up

Table 5 Severe deficits at first follow-up in 24 patients with permanent or transitory dependance

Dependance N Age at When seen after PTA Number of deficitstrauma trauma

age N _ months - months physical cognitive person.(yr) X range X* range

1) Permanent 12 <21 8 33 12-50 58 35-90 8 9 10>21 4

2) Transitory 12 < 21 6 28 13-70 4-1 2-57-0 4 4 9>21 6

*Significantly different at 5% level (Mann Whitney rang sum test)

Nine had signs of brainstem involvement (type II).In table 5 patients with permanent and transitorydependance are compared according to deficits atthe first follow-up. It is seen that the majority hadsevere personality changes. However, while onlyone patient with transitory dependance presented acombination of severe physical, cognitive and per-sonality problems, six patients with permanentdependance did so. Table 5 also shows that thefirst follow-up in average took place more than twoyears after the trauma and that the PTA was long inboth groups, but significantly longer in cases withpermanent dependance than in those with transit-ory. It is also worth mentioning that while six withpermanent dependance had been psychotic only twowith transitory dependance had been so.

B. Neuropsychological sequelaeAt the first follow-up the WAIS performance scoresranged from 68-113. There was no significant dif-ference between patients below and above the ageof 21 years when injured (Mann Whitney rang sumtest). Nearly all had low auditory verbal memoryspan, and verbal and visual learning and recall werein the majority much below the results in a non headinjured control group.9

Language The frequency of communication disor-ders can be seen in table 6. Regarding intelligibilitydysarthria presented the most serious permanentproblem. Eight were difficult to understand at thefirst follow-up. In one patient, who received speechtherapy for a long period, articulation improved dur-ing years, but subnormal rate and increased mono-tony persisted and so did the motor deficits. Elevenof the 15 dysarthric patients had motor impairmentand 12 had signs of brainstem damage.Nine of the 19 patients who initially presented

symptoms of aphasic type had focal lesions. Amnes-tic aphasia, verbal paraphasia and perseverationwere the most common dysfunctions in the earlystage and at the first follow-up.'0 Analysis of speechand reading had improved in several cases at the lastmentioned examination, bt three patients. were not-

able to do a test of silent reading and many amongthose who were considered non-aphasic, wereextremely slow and/or made mistakes. Few read anewspaper. At the second follow-up many patients,whether originally aphasic or not, responded slowlyand some needed repetition of questions. Subnor-mal rate of speaking, impaired word finding andsporadic verbal paraphasia of the semantic type,frequent pauses, the use of many set phrases, andperseveration on words and subjects were common.Aposiopesis, a condition in which a sentence is leftunfinished, was often observed. Four patients, allwith verified focal lesions in the left hemisphere,presented aphasic symptoms (table 6). In a man whohad had an extensive subdural haematoma extremeamnestic aphasia had improved since the firstfollow-up five years after the trauma, but agraphiaand severe dyslexia remained. The other threepatients had moderate impairment with in two casesa combination of aphasia and defects of memory.Only one aphasic patient had motor deficits.Nine patients and 17 relatives reported difficul-

ties. Three patients complained of impaired auditoryanalysis, in one case problems in recognising lowfrequency words, especially foreign ones, whichpremorbidly had been familiar. Six suffered fromslow speech, impaired word finding and problems inremembering what they wanted to say. The relativesof 14 patients declared that the patient easily losttrack of what was said and/or forgot what was men-tioned a moment ago. Three repeated themselvesconstantly.At the time of the second follow-up most patients

listened to the news on television, but 16 (40%)never read. All but one had subnormal reading atthe first follow-up.

Table 6 Disorders ofcommunication

L examinaton 2-5 years 1-S15 years

Aphasia 19 16 4Dysarthria 15 15 15

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Memory At the first follow-up 12 patients deniedmemory impairment, 13 gave evasive answers, suchas "I suppose I have a bit of trouble", "They say, mymemory is not good" etc., and 15 declared that theyhad problems. The relatives reported difficulties in alittle more than half the cases. However, clinicalobservation and cognitive assessment revealed thatat least 80% had memory defects (table 7). At thesecond follow-up poor memory was described in75% (table 7). Six patients with very severe defectswere hot always orientated in the hour of the dayand the day of the week. When sad, they forgot whyin few minutes. In less severe cases patients oftenhad problems in remembering names and appoint-ments and in misplacing things. Most patients hadduring the years realised their memory impairment,but a few declared that they had no difficulties whenasked in the interview. A moment later they spon-taneously gave examples thereof.The contingency table (7a) reveals that four

patients and their relatives denied memory defectsat both examinations. Three were aphasic at the firstone. A woman who had had an intracerebralhaematoma in the left temporal region had no gen-eral impairment 4 5 years after the injury, butsevere verbal dysfunction. She was not able to recallthe surnames of her two married daughters. Theremaining two aphasic patients had moderatedifficulties in recalling figures in a visual learningtask. They both returned to normal work two andfive years respectively after the trauma. The fourthpatient, an unskilled labourer, had paraplegia andsevere dysarthria with aphonia. Three years afterthe accident he started improving his schooling andpassed several examinations.

C. Psychosocial sequelaeBehaviour The problems reported at the first andsecond follow-up can be seen in table 7. While lackof social contact at the former was the greatest sub-

Table 7 Problems at first and second follow-up

2-5 years 0-15 years

Poor memory 80% 75%Changes in personality andemotion 80% 65%

childishness 60% 25%emotional lability 40% 35%irritability 38% 48%restlessness 25% 38%disturbed behaviour 23% 20%

Poor concentration 73% 53%Slowness 65% 53%Loss of social contact 60% 68%Aspontaneity 43% 53%Tiredness 28% 50%Sensitivity distress 23% 68%Lack of interests 20% 55%

Thomsen

jective burden to the patients, changes in personalityand emotion presented the severest problem to thefamilies. The spouses of the seven patients who hada divorce declared that their wives or husbands hadbecome complete strangers. Loss of emotional con-trol, with rapid changes between apathy and aggres-sion, irritability, and childishness were the maincomplaints. The relationship between the patientsand their children developed badly in all cases andthe spouses considered themselves the only grown-ups in the families. The parents, especially themothers of single patients, often described childish-ness, which in some cases initially was outstanding.When a 20-year-old man with a type II lesionreturned to his parents four months after the injury,he behaved like a child of one. He followed hismother everywhere grasping her apron and con-stantly tried to open doors, cupboards and drawers.The young psychotic girl with the fronto-orbitalfractures (table 4) presented an even more extremeregression, returning to a foetal-body pattern andbehaving like a baby."At the second follow-up several relatives reported

gradual improvement in behaviour during the firstfive to six posttraumatic years. However, informa-tion from patients and relatives indicated that twothirds had permanent changes in personality andemotion (table 7). A statistically significant netreduction over time was found in childishness(tables 7 and 7a), but in the most severe cases, as thetwo referred, the patients remained dependant.Table 7a also reveals that regressive features nearlyalways were recognised during early stages. Withreference to emotional lability, irritability, restless-ness and disturbed behaviour, fluctuations tookplace over time (table 7a). Table 7b shows that thefrequence of these dysfunctions was much higher inthe young than in the older ones and a significantdifference was present in the last three mentionedproblems (when tested by means of Chi squaredemotional lability also reached significance, butwithout Yates correction). Furthermore practicallyall late deficits, that is after the first follow-up,occurred in the young (table 7a). Disturbedbehaviour was the most infrequent change of all, butwas viewed seriously of the relatives. A fifth hadpermanent troubles, such as aggressiveness and lackof sexual inhibition, including a case of promiscuity.All were in the age group 15-21 when injured (table7b). Among the five who recovered (table 7a), fourhad been verbally aggressive and one, a woman of37 when injured, had been hypersexual. She had atype I lesion with signs of bitemporal lesions (per-manent EEG findings) and a PTA of 5 months. Shewas married and had children, but was divorced. Atthe second follow-up she had for some years had a

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Late outcome of very severe blunt head trauma: a

Table 7a Contingency tables

Problems at first (I) and second (II)Poor memory

I

yesyes 26

II no 6

all 32Childishness

I

no all4 304 108 40

yes no

II yes 8 2t

no 16 14

Emotional lability

yes

no 9

Irritability

yesyes 10

I, no 5

Restlessness

I

no7x)

17

nogx)

16

yes no

I yes 7 8x)no 3 22Disturbed behaviour

yes no

I yes 4 4x)no 5 27

x): all or all but ones 21 years

McNemar's test for significance of clat 5% level, tsignificantly differentferent at 1% level

sexual relationship with a p

father. She spontaneously d

contrast to her premorbid liapart from her sexual needtraumatic years.

A statistically significantent in impairment of conceihowever, important to beaiinvolved themselves in intireading a book. A statiincrease was found in tire(and sensitivity distress, andnever occurred. Tiredness wwas most frequent among c

ence between the age grotinterests, and sensitivity disin the young (table 7b). Whtioned change created troubman with a PTA of 7 monthramme, bathing, eati-ng, rea

taking his routine walk atevery day. It is also importaerate increase in aspontan

quency of permanent lack of initiative in the young

follow-up (tables 7 and 7b).foUow-up___________ At the second follow-up two thirds had no contactPoor concentration outside the close family (table 7), and social isola-

yes no tion remained the patients' severest burden. HardlyIIyes 17 4 any had been able to keep in touch with premorbid

no 12 7 friends and very few made but casual acquaintancesSlowness ("people I meet in the bus" etc.). Several preferred

I to make friends with old people, since they wereyes noI yes 18 3 kind and patient. At least three had or had had sex-

no 8 11 ual relationships with partners at the age of theirLoss ofsocial contact parents.

yes no In contrast to the majority, eight had but fewyes 18 8 problems. Tiredness was the most frequent com-Aspontaneity plaint. Half the patients had a PTA exceeding 3

I months.yes no

I yes 11 10no 6 13 Work capacity In the years between the follow-upTiredness examinations 12 patients had attended courses at a

yes no "hoejskole", that is a boarding school for grown-sno 1 19t ups, and some did so twice.Sensitvity to stress At the second follow-up 37 (93%) had a disable-and changes ment pension. Only three had or had had full-time

yes no work (table 8). The physically strong, but severelyI yes 9 18* aphasic man who had had a left subduralno 0 13 haematoma, mentioned before, had twenty jobs or

Lack of interestsI so in the first five posttraumatic years. He then

yes no became a truck-driver and was still employed in theyes 7 15*no 1 17 firm ten years later. He was not able to write his

anges. *significantly differen timesheet. A woman, aged 24 when injured with a

at 1% level, $significantly dif- type I lesion and a PTA of 3 months, was consideredseverely regressive two years after the accident, inwhich she lost her husband and only child. She

artner at the age of her started working as an unskilled labourer six yearseclared that she, in deep after the injury, but had to stop two years later afterife, had had no interests childbirth. Finally a man, aged 17 years whenIs for the first five post- injured with a left temporal lesion (type III) and a

PTA of 2-5 months, returned to his job as a baker'snet reduction was pres- apprentice. He finished his training, but left the jobntration (table 7a). It is, and worked as an unskilled labourer for severalr in mind that very few years. It is also seen in table 8 that two had part-time:ellectual tasks, such as work. The one, a woman with a PTA of one month,istically significant net worked as a clerk and had no complaints exceptdness, lack of interests, tiredness, the other, a male piano-tuner, had signs ofimprovement practically severe memory impairment, but had apparently notras the only problem that lost his professional skill.)Ider patients, no differ- While at the first follow-up very few had been in,ips was seen in lack of contact with local rehabilitation centres, 23 had,tress was most common been so at the second. One patient, a farmer, hadten severe, the last men- been trained as a book-keeper, but was not emp-les in daily life. A young loyed. The patient with the rigid programme of theis thus kept a rigid prog- day had tried several jobs at a very basic level fording his newspaper and eight years, but all in vain. Seven had got paid shel-exactly the same time tered work (table 8). One, a man of 44 when

tnt to mention the mod- injured, had had a left subdural and epiduralLeity and the high fre- haematoma and a PTA of 5 months. He remained

10-15 year second follow-up 265

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Table 7b Frequency ofproblems in patients with deficits at second follow-up

Problem

Poor memory

Childishness

Emotional lability

Irritability

Restlessness

Disturbed behaviour

Poor concentration

Slowness

Loss of social contact

Lack of spontaneity

Tiredness

Sensitivity, distress

Lack of interests

A: presentB: absentA:B:A:B:A:B:A:B:A:B:A:B:A:B:A:B:A:B:A:B:A:B:A:B:

Age at trauma

-21y.no. 23

18 (78%)5 (22%)7 (30%)16 (70%)11 (48%)12 (52%)15 (65%)8 (35%)

13 (57%)10 (43%)8 (35%)15 (65%)14 (61%9 (39%~

13 (57%)10 (43%)17 (74%)6 (26%)

15 (65%)8 (35%)

10 (43%)13 (57%)18 (78%)5 (22%)

13 (57%)10 (43%)

Total no.

>21y.no. 17

12 (71%)5 (29%)3 (18%)14 (82%)3 (18%)14 (82%)4 (24%)13 (76%)2 (12%)

15 (88%)0 ( O*)17 (100%)7 (41%)10 (59%)8 (47%)9 (53%)

10 (59%)7 (41%)6 (35%)

11 (65%)10 (59%)7 (41%)9 (53%)8 (47%)9 (53%)8 (47%)

30101030142619*2115t258*

322119211927132119202027132218

Fishers exact test for significance of difference in frequency in age groups.*significantly different at 5% leveltsignificantly different at 1% level

Table 8 Work capacity at 1st and 2nd follow-up

No. ofpatients Patients entering(+) or leaving

2.5 yr. 10-15 yr.(-) group

Full-time 2 3 +1Part-time 4 2 -2Retrained, unemployed 0 1 +1Paid sheltered work 3 7 -1+5Attending courses 1 2 -1+2Homeminders 1 3 + 2

severely aphasic for many months, but started work-ing in the Royal Library two years after the trauma.He was extremely orderly and had at the secondfollow-up the responsibility of half a million indexcards.12 Another patient, a man of 20 when injured,with a type II lesion and a PTA of 6 months hadslow waves down to 1*0 Hz over both hemispheres a

week after the accident. Three years later the WAISperformance score was 68. At the time of the secondfollow-up he had been working the past four yearsas a gardener's assistant at a hospital. His employerpraised his behaviour, industry and initiative. Twopatients had such severe motor impairment thatsheltered work was not possible. They- improvedtheir schooling (table 8). One, a man with parap-

legia, has been mentioned. The case of the other, alocksmith, aged 19 when injured, is thought-provoking. He had a type II lesion and did notrespond verbally or non-verbally to speech untilfour months after the trauma. The PTA was 7months. There was severe hypertonia in both armsand legs and contractures. Operations were not suc-cessful. One year after the accident he was totallydependant with dysarthria, severe emotional regres-sion but only moderate cognitive deficits. He was ina nursing home for three years without muchimprovement. According to his own explanation hethen started asking himself, whether he wanted tospend the rest of his life in this way. A year later hewent to a "hoejskole" and stayed there for a year.At second follow-up he lived alone and had taughthimself to walk indoors. He hoped to obtain"studentereksamen", that is admission to universityand had passed in half the subjects, but had takenmuch longer time than normally. He had manyfriends.

It is also worth mentioning that three women wereable to manage their housekeeping and shoppingthemselves. One with permanent aphasia had notrouble either at the first follow-up, the remainingtwo were at that time unable to do any piece of workon their own. They. were among those who weredivorced.

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Discussion

In the present investigation on late outcome in verysevere head trauma no one escaped permanentsequelae. More than a quarter remained dependantand practically all received disablement pension.The worse overall outcome was found in cases withbrainstem involvement and/or severe verifiedanterior lesions.The frequency of motor impairment was much

higher in this sample than in cases with severe headinjury but a shorter PTA.' 2 Several recovered dur-ing the first year or two, but a third remainedseverely disabled. The presence and degree of brain-stem damage was crucial. This was also the caseregarding dysarthria, the most serious permanentdisorder of communication in the material. Recov-ery was better in aphasia, at least as far as functionalcommunication is concerned, but few, if any,regained their premorbid language abilities. In thecourse of time the discrepancy between aphasic andnonaphasic patients frequently diminished. Thesequelae of severe diffuse neuronal damage, such asdefects of memory and concentration and slownessbecame predominant features and the linguisticdeficits could often be described as instances of gen-eral mental impairment.'3 Sarno'4 found in a recentinvestigation of patients with closed head traumathat no one escaped some degree of verbal dysfunc-tion. The results in the present late study indicatethat language impairment, at least in very severecases, is permanent, but not often in form of aphasiaper se. In contrast to the findings of McKinlay et a16disorders of communication, especially dysarthria,often presented severe problems to patients andrelatives.

Psychoses only occurred in cases with a PTA ofmore than 3 months and often in connection withverified anterior lesions and/or severe left hemis-phere damage.'5 Most patients remained dependant.Changes in behaviour continued to be a most

serious burden and though some fluctuation insymptoms took place, the frequency did not changepositively, except in childishness. The absence of theproblem at the first follow-up was a good predictorthat it would still be absent in later stages, but itspresence at the first follow-up was not a good pre-dictor of its presence later on. The opposite was thecase in tiredness, lack of interests and sensitivity dis-tress, with the presence of the symptoms at firstfollow-up being a very good predictor of their pres-ence later on, but their absence at first follow-upbeing a poor predictor of their absence in laterstages.While a spectrum of intolerable problems was

reported in married patients at the first follow-up,

the young had the greatest frequency of permanentchanges, in particular in personality and emotion.The majority of late problems was also found in thisgroup. McKinlay et a16 have reported similar lateincrease of emotional difficulties in head injuredpatients during the first posttraumatic year. Theircases were severe, but PTA was generally muchshorter than in the present sample and the resultsmay, in spite of the different lapse of time, reflectthe same mechanisms. It is not possible to provewhether the late dysfunctions were direct results ofthe trauma or reactions to disabilty. Clinical obser-vation at the first follow-up suggested that somerelatives, especially parents, only slowly came toaccept the full extent of changes.7 The differentreactions of spouses and parents were striking, theformer expressing only too realistic views, the latterthe opposite. As to the patients themselves lack ordemise of insight were generally more pronouncedand more long-lasting in the young than in the olderpatient. As assessed by the PTA there was no statis-tically significant difference in the severity of cere-bral injury in the two age groups. The young had thegreater number of severe anterior lesions, but thefocal damage was in all cases accompanied by verysevere diffuse neuronal damage. The results in thisstudy may indicate that the immature personality isparticularly vulnerable in severe head trauma.

Loss of social contact remained the patients' mostdisabling handicap in daily life. Not only patients butalso families became isolated. Great permanentdifficulties were described in cases, where parentslived with a severely disabled son. The relationshipbetween father and son easily became strained andthe family became isolated, because the siblingsstopped visiting.'6

Studies have indicated that the greatest recoveryoccurs in the first six months,'7 but that there is avarying pattern in the individual patients'8 and thatimprovement is possible as long as three years afterthe injury.3 In the present investigation many exam-ples have been given of long-term improvement infunctional state. It is especially remarkable that halfthe patients who could not be left alone two years ormore after the accident became independent duringthe following years. Several in the sample regainedat least some work capacity, but generally not untilyears after the injury. The late results thus indicatethat though the patient with very severe headtrauma may remain disabled, improvement inpsychosocial functions can continue for severalyears.

This investigation was supported by a grant from theDanish Ministry of Social Affairs no. 4.10.53.02.

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I remember with deep gratitude the late ProfessorErik Skinh0j for inspiration and crucial support inthe study of patients with severe head trauma.Thanks are due to Dr Neil Brooks for helpful critic-ism of this paper.

References

Miller H, Stern G. The long-term prognosis of severe

head injury. Lancet 1965;1:225-9.2 Fahy TJ, Irving MH, Millac P. Severe head injuries: a six

year follow-up. Lancet 1967;2:475-9.Najenson T, Mendelson L, Schechter I, David C, Mintz

N, Grosswasser Z. Rehabilitation after severe headinjury. Scand J Rehab Med 1974;6:5-14.

London PS. Some observations on the course of eventsafter severe injury of the head. Ann R Coll Surg Engl1967;41:460-79.

Bond MR. Assessment of psychosocial outcome aftersevere head injury. In: Outcome of Severe Damage tothe CNS. Ciba Foundation Symposium 1975;34:141-53.

6 McKinlay WW, Brooks DN, Bond MR, Martinage DP,Marshall MM. The short-term outcome of severe

blunt head injury as reported by relatives of theinjured persons. J Neurol Neurosurg Psychiatry1981;44:527-33.

Brooks DN, McKinlay WW. Personality and behaviouralchange after severe blunt head injury-a relative'sview. J Neurol Neurosurg Psychiatry 1983;46:336-44.

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8 Thomsen IV. The patient with severe head injury and hisfamily. Scand J Rehab Med 1974;6:180-3.

Thomsen IV. Verbal learning in aphasic and non-aphasicpatients with severe head injuries. Scand J Rehab Med1977;9:73-7.

'° Thomsen IV. Evaluation, outcome and treatment ofaphasia in patients with severe head injuries. In: SarnoMT, Hook 0, eds. Aphasia. Assessment and Treat-ment. Stockholm: Almqvist & Wiksell, 1980:181-5.

Thomsen IV, Skinh0j E. Regressive language in severehead injury. Acta Neurol Scand 1976;54:219-26.

12 Thomsen IV. Neuropsychological treatment and longtime follow-up in an aphasic patient with very severehead trauma. J Clin Neuropsychol 1981;3:43-51.

3 Levin HS, Grossman RG, Kelly PJ. Aphasic disorder inpatients with closed head injury. J Neurol NeurosurgPsychiatry 1976;39:1062-70.

14 Sarno MT. The nature of verbal impairment after closedhead injury. J Nerv Ment Dis 1980;168:685-92.

'5 Lishman WA. The psychiatric sequelae of head injury: areview. Psychol Med 1973;3:304-18.

16 Oddy M, Humphrey M. Social recovery during the yearfollowing severe head injury. J Neurol NeurosurgPsychiatry 1980;43:798-802.

17 Bond MR, Brooks DN. Understanding the process ofrecovery as a basis for the investigation of rehabilita-tion for the brain injured. Scand J Rehab Med1976;8:127-33.

18 Brooks DN, Aughton ME. Cognitive recovery duringthe first year after severe blunt head injury. Int RehabMed 1979;1:166-72.

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