eMedicine Specialties > Neurosurgery > Trauma

Penetrating Head Trauma: Follow-up

Author: Federico C Vinas, MD, Consulting Neurosurgeon, Department of Neurological Surgery, Halifax Medical Center
Coauthor(s): Julie Pilitsis, MD, Staff Physician, Department of Surgery, Division of Neurosurgery, Wayne State University
Contributor Information and Disclosures

Updated: May 27, 2009

Outcome and Prognosis

Many studies have attempted to associate various prognostic factors with outcome. The most important prognostic factor currently recognized is the GCS after cardiopulmonary resuscitation. Traditionally, the higher the GCS after resuscitation, the better the patient outcome. However, concern has developed that, because patients who present in coma are thought to have a dismal prognosis, less aggressive management is often used, contributing to the poorer outcome.

Studies over the last decade have examined the outcome of patients with a postresuscitation GCS of 3-5 who underwent aggressive medical and surgical management. Grahm et al (1990) found that no patient in a study of 100 patients with postresuscitation GCS of 3-5 had a satisfactory outcome (good/moderately disabled).6 They also found that no patients with a GCS of 6-8 and bihemispheric or multilobar dominant hemisphere injuries had a satisfactory outcome.

In a review of 190 patients, Levy et al (1994) found that only 2 patients with a GCS of 3-5 achieved a moderately disabled outcome.7 Further analysis showed that these patients had reactive pupils at admission and did not have bihemispheric/multilobar dominant hemispheric injuries. They concluded that surgical intervention is not beneficial in most patients with a GCS of 3-5 but may be beneficial for the rare patient with reactive pupils but without ominous findings on CT scan. Despite these studies, some controversy remains regarding surgery performed on patients with a GCS of less than 9 and especially regarding patients with a GCS of less than 5.

Other poor prognostic factors include age, suicide attempt, and through-and-through injuries. Patients who present with high ICP and/or hypotension also tend to have worse outcomes. CT scan findings associated with poor outcome include (1) bihemispheric injury, (2) intraventricular and/or subarachnoid hemorrhage, (3) mass effect and midline shift, (4) evidence of herniation, and/or (5) hematomas greater than 15 mL on CT scan.

Morbidity and mortality rates associated with penetrating brain injury remain unacceptably high. For patients presenting with a GCS of 3-5, mortality rates remain near 90%, and a satisfactory outcome as defined by the GCS only rarely occurs. Patients presenting with a GCS of 6-8 have a more variable outcome that may be related to differences in management and/or the smaller numbers of patients presenting in this category. Patients with a GCS greater than 9 have much lower mortality rates. Approximately one half of these patients make good recoveries, and 90% have satisfactory outcomes.

Future and Controversies

Many penetrating head injuries are incompatible with life, and people with these injuries often die almost immediately. Moderately injured patients more frequently are resuscitated and receive treatment. Upon presentation, beginning aggressive medical and surgical treatment is important in patients who may benefit from these interventions. Aggressive treatment of secondary mechanisms of injury must be initiated, and the patient must be monitored closely for possible complications.

Kaufman et al (1991) found that considerable variability exists among neurosurgeons currently as to what constitutes appropriate treatment of penetrating head injury.8 In particular, wide variations exist in the amount of surgical debridement performed, the use of ICP monitoring, and the use of various medical therapies. Duration of antiepileptics and antibiotics remains controversial, as does the use of hyperventilation, hypothermia, and steroids. Use of jugular bulb catheters and transcranial Doppler is institution-dependent.

Considerable research continues in the area of neurotrauma. Once secondary mechanisms of injury are better understood and treatment modalities are studied in prospective randomized clinical trials, less variation in management of penetrating head injury is likely to occur. The medical community as a whole will become more successful in the treatment of these patients.

Aggressive intensive care management in combination with surgical intervention, when appropriate, already has significantly reduced the mortality and morbidity associated with these injuries. Primary prevention of these injuries remains important. With the increasing numbers of firearms and firearm-related violence in our society, discussing the issues of violence with patients and offering appropriate intervention becomes the duty of all health care providers.

 


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Multimedia: Penetrating Head Trauma
References
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Further Reading

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Keywords

trauma, brain injury, penetrating head trauma, head trauma, open intracranial injuries, penetrating injuries, Glasgow Coma Scale, GCS, GCS score, traumatic brain injuries, TBIs, brain trauma, intracranial trauma, intracranial pressure, ICP, gunshot wounds, GSWs, head injury

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Contributor Information and Disclosures

Author

Federico C Vinas, MD, Consulting Neurosurgeon, Department of Neurological Surgery, Halifax Medical Center
Federico C Vinas, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, Congress of Neurological Surgeons, Florida Medical Association, and North American Spine Society
Disclosure: Nothing to disclose.

Coauthor(s)

Julie Pilitsis, MD, Staff Physician, Department of Surgery, Division of Neurosurgery, Wayne State University
Julie Pilitsis, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Michael G Nosko, MD, PhD, Chief, Division of Neurosurgery, Director of Neurovascular Surgery, Medical Director of Neuroscience Unit, Associate Professor, Department of Surgery, University of Medicine and Dentistry of New Jersey
Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Ryszard M Pluta, MD, PhD, Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Senior Researcher, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, NIH
Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD, Former Medical Director, Northstar Neuroscience, Inc
Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons
Disclosure: Nothing to disclose.

 
 
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