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Closed Head Injury Clinical Presentation

  • Author: Leonardo Rangel-Castilla, MD; Chief Editor: Brian H Kopell, MD  more...
 
Updated: Feb 24, 2016
 

Physical

The Glasgow Coma Scale (GCS), first introduced by Teasdale and Jennett in 1974, has been the standard for objectively assessing individuals with traumatic head injuries (see Table 2).[38] It comprises motor, verbal, and eye scores. The overall score generally refers to the best response/examination obtained within the first 6-8 hours after injury and following resuscitation and is considered to be a predictor of the patient's overall outcome.[39, 40, 41, 13, 42]

The GCS has 2 main advantages in that it provides a reproducible, objective evaluation of neurological status, and it is a relatively simple way to monitor a patient's neurological condition over time. The GCS has shortcomings because its reliability depends on the absence of confounding factors (eg, sedation, paralytics, hypothermia, hypotension, hypoxia). Additionally, it cannot compensate for lack of eye opening in patients with periorbital trauma or loss of verbal response in intubated patients, and it omits brainstem reflex assessment.[43, 44]

Most clinicians assign a verbal score of 1 and apply the modifier "T" to intubated individuals. This may not be an accurate assessment of the patient's true verbal score.[45] The motor component of the GCS score is most predictive of the severity of the brain injury and correlates most strongly with overall outcome.[45]

The GCS score is often used to categorize the severity of head injury into mild (15-13), moderate (12-9), or severe (8 or less). In general, mild head injury does not usually involve significant primary brain injury, is not associated with neurological deficits, and may or may not include loss of consciousness. Approximately 75% of head injuries are categorized as mild to moderate in nature.[46] Most authorities agree that a patient with a severe head injury is one who is unconscious and unable to follow simple commands.

Table 2. Glasgow Coma Scale (Open Table in a new window)

Best Motor Response Obeys commands 6
Localizes 5
Withdraws (abnormal flexion) 4
Flexion (decorticate posturing) 3
Extension (decerebrate posturing) 2
No response 1
Verbal Response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Eye Opening Spontaneous 4
To command 3
To pain 2
No response 1
Total   3-15

 

Patients should also be evaluated for basic brainstem reflexes. This assessment includes the evaluation of pupillary reflex, corneal reflex, gag/cough reflex, oculocephalic reflex, vestibuloocular reflex, and spontaneous breathing. Pupillary asymmetry or anisocoria of more than 1 mm (up to 1 mm may be physiological) must be attributed to an intracranial lesion until proven otherwise.[45]

Careful attention must be given to the evaluation of spontaneous breathing in the ventilated patient. A common pitfall is to mistakenly assess a patient as taking spontaneous breaths when the sensitivity on the ventilator is set to a level that triggers a mechanical breath at the slightest effort by the patient.

Proper evaluation entails setting the ventilator sensitivity to zero, then reevaluating the patient after a few seconds, which does not allow time for hypoxia or hypercapnia to develop. The presence of any of the above reflexes confirms that the patient has at least basic brainstem reflexes. A complete absence of brainstem reflexes is an ominous sign.

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Causes

Causes include the following:

  • Motor vehicle collisions
  • Motorcycle collisions
  • Assaults
  • Falls
  • Other
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Contributor Information and Disclosures
Author

Leonardo Rangel-Castilla, MD Fellow in Cerebrovascular and Skull Base Neurosurgery, Barrow Neurological Institute

Leonardo Rangel-Castilla, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons, Neurocritical Care Society

Disclosure: Nothing to disclose.

Coauthor(s)

Paul Salinas, MD Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston

Disclosure: Nothing to disclose.

Fadi Hanbali, MD, FACS Associate Professor, Division of Neurosurgery, Department of Surgery, Texas Tech University Health Sciences Center; Associate Professor, Department of Orthopedic Surgery, Texas Tech University Health Sciences Center; Adjunct Professor, Departments of Neurosurgery and Orthopedic Surgery, Division of Neurosurgery, University of Texas Medical Branch

Fadi Hanbali, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Jaime Gasco, MD Staff Physician, Department of Neurosurgery, University of Texas Medical Branch School of Medicine

Jaime Gasco, MD is a member of the following medical societies: American Association of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ryszard M Pluta, MD, PhD Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Polish Society of Neurosurgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Paul L Penar, MD, FACS Professor, Department of Surgery, Division of Neurosurgery, Director, Functional Neurosurgery and Radiosurgery Programs, University of Vermont College of Medicine

Paul L Penar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, World Society for Stereotactic and Functional Neurosurgery, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

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CT scan of left frontal acute epidural hematoma (black arrow) with midline shift (white arrow). Note the left posterior falx subdural hematoma and left frontoparietal cortical contusion.
CT scan of left frontoparietal acute subdural hematoma (black arrow). Note the moderate amount of midline shift.
CT scan of bilateral acute intraventricular hemorrhages (black arrow). Note the comminuted skull fractures that involve bilateral frontal, temporal, and parietal bones (white arrow). Note the ischemic changes in both frontal lobes, subarachnoid hemorrhages in the intrahemispheric fissure and left frontal lobe, and multiple intraparenchymal hemorrhages in both frontal poles.
MRI of the brain that shows diffuse axonal injury (DAI) and hyperintense signal in the corpus callosum (splenium), septum pellucidum, and right external capsule.
MRI of the brain (sagittal view) that shows a Duret hemorrhage in the splenium of the corpus callosum.
Cerebral blood flow/cerebral perfusion pressure chart.
Table 1. American Academy of Neurology Concussion Grading Scale
Grade 1 Grade 2 Grade 3
Transient confusion Transient confusion ...
No loss of consciousness No loss of consciousness Brief or prolonged loss of consciousness
Concussion symptoms or mental status change resolves in 15 min or less Concussion symptoms or mental status change resolves in more than 15 min  



...



Table 2. Glasgow Coma Scale
Best Motor Response Obeys commands 6
Localizes 5
Withdraws (abnormal flexion) 4
Flexion (decorticate posturing) 3
Extension (decerebrate posturing) 2
No response 1
Verbal Response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Eye Opening Spontaneous 4
To command 3
To pain 2
No response 1
Total   3-15
Table.
Advantages Disadvantages
Noninvasive and rapid Traumatic vascular lesions may be missed.
Very sensitive for acute hemorrhage DAI is likely to be missed.
Defines nature of ICH (ie, SDH, SAH) Motion artifact may limit study.
Defines anatomical location of lesion Posterior fossa lesions are poorly depicted.
Identifies fractures of the cranium Depressed skull fractures at the vertex (or along the plane of an axial scan) are poorly depicted.
Sensitive to detecting intracranial air The scanner has a weight limit, and a patient may be too heavy.
Sensitive in identifying foreign objects A patient may decompensate while in the scanner.
*Intracranial hemorrhage



†Subdural hemorrhage



‡Subarachnoid hemorrhage



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