eMedicine Specialties > Neurology > Neurological Emergencies

Head Injury: Follow-up

Author: David A Olson, MD, Clinical Neurologist, Dekalb Neurology Associates, Decatur, Georgia
Contributor Information and Disclosures

Updated: Jun 8, 2009

Follow-up

Further Inpatient Care

This needs to be individualized. Certainly after a moderate or severe head injury, transfer to an inpatient rehabilitation unit is recommended.

Further Outpatient Care

This also depends on the degree of the head injury and the individual patient's cognitive and motor abilities and pain complaints.

Inpatient & Outpatient Medications

See Medical Care.

Transfer

Patients with moderate or severe head injuries and head injuries with significant extracranial components are cared for best at a specialized trauma center.

Deterrence/Prevention

  • Reducing morbidity and mortality rates associated with head injuries is likely to be difficult. Violence, automobiles, and drug and alcohol use are prevalent.
  • A study of community-based programs reported modest success, primarily by employing increased police surveillance and law enforcement to reduce overdrinking and alcohol-related injuries. Motor vehicle accidents in which the driver was intoxicated declined 6%, and more significantly, overall assault cases seen in local emergency departments decreased 42%.103
  • Another study has shown that patients who were screened for alcohol problems and provided with an organized intervention to reduce their alcohol consumption exhibited a 47% decrease in emergency department–evaluated injuries compared to patients receiving no alcohol screening or intervention.104
  • The use of protective devices also is promising. A meta-analysis of case-control studies of bicycle helmet use concluded that helmets reduce the risk of severe head and brain injuries by 63-88%.105 Indeed, a 2006 study of 160 cyclist injuries in Singapore found that helmet users sustained head injuries only 5.9% of the time, compared with 40% of the time for nonusers.106 Similarly, a California law mandating the use of bicycle helmets for riders aged 17 years and younger reduced traumatic brain injuries by 18%. However, subgroup analysis revealed that this reduction failed to apply to urban, female, and African American riders.107

Complications

  • Mild head injury
    • Mild head injuries are those that generate GCS scores of 13-15. Such injuries usually are considered relatively benign, and the accompanying cognitive impairments typically resolve within 3 months of injury.
    • Patients with lingering complaints are often assumed to have either a psychological reaction to the injury or to be malingering. Various standardized neuropsychologic instruments are available to help sort out legitimate from illegitimate cognitive impairments. About 25% of patients with mild head injury taking such tests yield invalid profiles.108
    • However, an initial grading of mild does not necessarily mean a mild outcome. As many as 3% of patients with an initial mild injury may require a neurosurgical operation.109 Some patients have died hours after sustaining trivial head injuries. Also, as previously mentioned, axonal damage has been documented pathologically with mild head injuries.
    • Disability rates may be pronounced with putatively mild injuries as well. Recent studies have demonstrated that following mild head injury, only 54-79% of patients are able to return to full preinjury employment. One study of 148 patients with mild head injury discovered that after 1 year, 26% had moderate disability and 3%, severe disability. Significant neuropsychological dysfunction, primarily of attentional and memory domains, may persist after mild head injury alone. Irritability and fatigue may linger as well.110
  • Second impact syndrome
    • In the United States, athletic competitions account for 300,000 mild head injuries per year. The second impact syndrome occurs when an athlete suffers a minor concussion and subsequently is re-injured in play. The repeated concussive events are theorized to result in autoregulatory dysfunction and vascular congestion. Catastrophic brain edema, herniation, and sudden death may ensue.
    • At least 35 cases occurred among US football participants from 1980-1993, but the general incidence of this syndrome is unknown. Concerns about athletes at risk returning to play too soon have generated formalized recommendations from the American Academy of Neurology. Return to play is postponed for increasing lengths of time depending on the severity of the concussion.111
    • Some researchers have questioned the existing literature's documentation of initial injuries, hypothesizing that the second impact syndrome is more one of primary impact and that secondary prevention strategies are not justified empirically.112 Other researchers more recently have stressed the prolonged nature of recovery from athletic head injuries and the need for longer recuperation prior to return to play.113
  • Posttraumatic epilepsy
    • Posttraumatic seizures occur clinically in approximately 4% of patients with head injuries within the first week of the injury. Continuous EEG monitoring has disclosed a higher incidence (22%).64
    • Seizures after the first week occur in 4-30% of patients. The severity of the head injury, early seizures, depressed skull fractures, and temporal and frontal injuries identified on CT scans all have been associated with the development of late seizures.114
    • Although focal EEG findings traditionally have not been predictive of late seizures, one study reported that a focal EEG 1 month after injury resulted in a 3.49-times higher risk of posttraumatic epilepsy.115
    • Recently, MRI-visualized hippocampal sclerosis has been associated with intractable epilepsy in patients who sustained moderate-to-severe head injuries when aged 10-31 years.116
  • Posttraumatic headaches
    • Posttraumatic headaches are common and may occur in 30-80% of patients after a head injury. The alterations in cations, catecholamines, and excitatory amino acids are similar in both migraine and head injury.117
    • Posttraumatic headaches typically manifest with a vascular component, but chronic daily headaches are also common.
    • Although controversial, some authors have reported that most posttraumatic headaches are primarily rebound or analgesic-overuse headaches. Nearly three fourths of such patients may benefit from cessation of pain medications.118
    • Greater occipital neuralgia can occur following head and neck injuries. Greater occipital nerve pain occurs in the back of the head and may be characterized by lancinating or aching sensations in this region.
  • Posttraumatic movement disorders
    • Tremor, dystonia, parkinsonism, myoclonus, and hemiballism all can occur following head injuries.
    • In a 2-year follow-up study of 398 patients with severe head injuries, 12% had persistent movement disorders. Disabling dystonia and low-frequency kinetic tremors were present in 5.4%. Parkinsonism and myoclonus attributable to the injury occurred in less than 1% of patients.30
  • Posttraumatic psychiatric disorders
    • Disorders of emotional functioning have been documented repeatedly after head injuries. A case-control study of 91 patients hospitalized with traumatic brain injury recorded a 33% incidence of major depression.119  Depression has been associated with left frontal injuries. Bipolar disorder is also more frequent in patients with head injuries than in the general population and is associated with seizures and right hemispheric lesions.
    • Additionally, impulsive and disinhibited behaviors are common in patients with frontal injuries, although even obsessive-compulsive features have also been reported.120
    • Head injury-related psychosis is controversial. A case-control study of 45 patients with psychosis following head injury found that auditory hallucinations and paranoid delusions developed after a 54-month postinjury latent period. More widespread injury on neuroimaging and decreased cognitive functioning characterized the psychotic patients with head injuries compared with nonpsychotic control patients with head injuries.121

Prognosis

  • This discussion has delineated a myriad of prognostic factors. Head injuries may result in death, a vegetative state, partial recovery, or full return to work. Each patient presents with a unique baseline neurological make up, mechanisms of injury, secondary complications, and postinjury adjustment and support system.
  • The most important prognostic factors are probably age, mechanism of injury, postresuscitation GCS score, postresuscitation pupillary reactivity, postresuscitation blood pressures, intracranial pressures, duration of posttraumatic amnesia or confusion, sitting balance, and intracranial pathology identified on neuroimaging.
  • The mortality rate of severe head injuries ranges from 25-36% in adults within the first 6 months after injury. Most deaths occur within the first 2 weeks.
    • A current study of 216 patients hospitalized during 2003-2005 in Ireland found 97% of patients with mild head injury attained a good recovery as measured by the Glasgow Outcome Scale, while 82% of the patients with severe head injury were either vegetative or markedly disabled. After 1 year, 11% of the total patients were unable to work.122
    • Another contemporary study of 309 Italian patients with moderate head injury found that only 15% were vegetative or severely disabled after 6 months. Basal skull fractures, subarachnoid hemorrhages, coagulopathies, subdurals, and poor emergency room clinical status predicted these unfavorable outcomes.44
    • Conversely, in Germany only 82% of 67 patients with mild or moderate head injury experienced a good 1-year outcome, and only 73% were able to return to work. Subjective complaints persisted in a large minority, with more than one third of patients reporting drowsiness, fatigue, forgetfulness, poor concentration, and irritability.123 Other studies have identified dizziness along with analgesic and psychotropic medication use as predictors of failure to return to work after mild and moderate head injuries.124
  • An Australian study of patients with head injuries incurred from 1984-1991 found that all 59 patients who were aged 65 years or older and scored less than 11 on the postresuscitation GCS either died or were left with severe disability. Future studies are needed to determine whether this grim prognostic indicator has more universal validity.125

Patient Education

  • The physician may be hesitant to suggest to patients that problems may arise from a mild head injury. Such information may induce the expectations of symptoms when no symptoms are present and arouse anxiety. However, at least one study has shown that patients with head injury who were contacted by phone and offered education about their injury and follow-up care experienced significantly fewer postconcussive symptoms and less disruption of social activities.126
  • At present, most patients incurring a head injury probably should be informed that cognitive and emotional dysfunction as well as head pain and other somatic symptoms are not uncommon in the aftermath. At least in mild injuries, these symptoms typically are self-limited, and most people return to normal functioning after a few weeks to months.
  • For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center, Dementia Center, and Eye and Vision Center. Also, see eMedicine's patient education articles Concussion, Dementia in Head Injury, and Black Eye.

Miscellaneous

Medicolegal Pitfalls

  • Head injuries and their sequelae are embedded inextricably in the medicolegal system. Both malpractice suits and tort litigation arise from the acute and long-term care of patients with head injuries.
    • A detailed history, review of systems, and complete examination is therefore essential.
    • Incorporate previous head pain, psychiatric treatments, and medication failures in the medical history.
    • Procure prior medical records, if possible, from emergency departments and other treating physicians.
    • Vague prior head injuries may become significant if emergency records report orofacial trauma or other clinical features that subsequently were forgotten or deemed unimportant by the patient and significant others.
    • Conversely, the patient's denial of preinjury head pain also may be significant if prior medical records reveal past treatment for migraines.
  • Documentation should be meticulous.
    • The physician must substantiate that a certain event likely induced a brain injury; delineate the physical, emotional, and cognitive consequences of that injury; and arrive at a prognosis for recovery.
    • The physician's findings and conclusions should rest securely on accessible and up-to-date published medical literature.
  • Relying on ancillary personnel or testing to the exclusion of the examiner's own evaluation can be perilous.
    • Subtle MRI abnormalities may not be included in the radiology report.
    • Discordance between bedside cognitive testing and quantitative neuropsychological testing can at times indicate malingering.
  • Adequately addressing long-term functional impairments is also paramount.
    • Driving independently is of particular importance to most patients. Although estimating driving ability on the basis of cognitive testing is difficult, some have found that visual spatial skills, reaction times, and awareness of deficits correlate with driving abilities. In some cases, actual road tests may be needed.127
    • Finally, patients with pain and emotional complaints that are refractory to standard management must receive documented referrals to appropriate specialists.
 


More on Head Injury

Overview: Head Injury
Differential Diagnoses & Workup: Head Injury
Treatment & Medication: Head Injury
Follow-up: Head Injury
Multimedia: Head Injury
References
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Further Reading

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Keywords

head injury, symptoms, treatment, coma, concussion, head trauma, traumatic brain injury, intracranial bleed, loss of consciousness, neuroprotection, skull fracture, subdural hemorrhage

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Contributor Information and Disclosures

Author

David A Olson, MD, Clinical Neurologist, Dekalb Neurology Associates, Decatur, Georgia
David A Olson, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Medical Editor

Joseph Carcione Jr, DO, MBA, Consultant in Neurology and Medical Acupuncture, Medical Management and Organizational Consulting, Central Westchester Neuromuscular Care, PC; Medical Director, Oxford Health Plans
Joseph Carcione Jr, DO, MBA is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Stephen A Berman, MD, PhD, Professor, Department of Internal Medicine, Section of Neurology, Dartmouth Medical School; Chief, Neurology Service, White River Junction Veterans Medical Center
Stephen A Berman, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

 
 
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