eMedicine Specialties > Neurosurgery > Trauma

Closed Head Trauma: Follow-up

Author: Leonardo Rangel-Castilla, MD, Staff Physician, Division of Neurosurgery, University of Texas Medical Branch School of Medicine
Coauthor(s): Jaime Gasco, MD, Staff Physician, Department of Neurosurgery, University of Texas Medical Branch School of Medicine; 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; Paul Salinas, MD, Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston
Contributor Information and Disclosures

Updated: Sep 22, 2009

Follow-up

Further Inpatient Care

Most patients require physical and occupational therapy, depending on the severity of the head injury.

Further Outpatient Care

Most patients with moderate-to-severe head injuries likely benefit from outpatient physical and occupational therapy. Once patients' acute issues have been addressed, many patients require cognitive rehabilitation (outpatient or inpatient).

Inpatient & Outpatient Medications

Initially, an anticonvulsant regimen should be started for patients with moderate or severe head injuries. Cease administration if no seizure activity occurs within the first 7 days after injury. For patients who have seizure activity in this time period, or who have undergone surgical procedures, one may opt to continue anticonvulsants for 6-12 months.

Transfer

Once the patient's acute issues have been addressed, seek long-term placement (eg, long-term acute care, skilled nursing facility, inpatient cognitive rehabilitation center) if the patient continues to require significant medical attention or assistance (eg, because of ventilation, need for significant nursing care).

Complications

See Secondary injuries.

Prognosis

  • The prognosis is affected by many factors, including (1) the type of injury (penetrating vs blunt), (2) severity of the injury and accompanying neurological deficit, (3) the age of the patient, (4) comorbid conditions, and (5) secondary injuries.
  • The Glasgow Coma Scale (GCS) has been reported to be the most predictive of neurological outcome at 1 year after severe head injury, while the 24-hour GCS score is the strongest predictor of cognitive recovery at 2 years after injury in patients with moderate-to-severe head injury.75,76
  • Pupillary function before and after resuscitation has some predictive value. In patients who initially have bilateral unreactive pupils (and whose pupils do not regain function), approximately 85% die or remain in a persistent vegetative state, compared with 15% of those who regain pupillary function.25
  • Age also influences overall outcome. Infants and very young children tend to have a higher mortality rate. This is most likely due to the nature of their injuries and associated prolonged episodes of apnea. The mortality rate from closed head injury remains relatively constant until after the age of 35 years, at which time it begins to rise dramatically.77
  • The development and duration of fever is clearly associated with worse prognoses.20

Patient Education

Educate the family about the type of injury the patient has sustained and what natural progression or recovery should be expected. The patient and the patient's family can be instructed regarding home exercises, wound care, and administration of long-term antibiotics.

Miscellaneous

Medicolegal Pitfalls

  • Misdiagnosis of initial injuries
  • Delayed care
 


More on Closed Head Trauma

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

Clinical guidelines
Davis PC, Brunberg JA, De La Paz RL, Dormont D, Jordan JE, Mukherji SK, Seidenwrum DJ, Turski PA, Wippold FJ II, Zimmerman RD, Sloan MA, Expert Panel on Neurologic Imaging. ACR Appropriateness Criteria® head trauma. [online publication]. Reston (VA): American College of Radiology (ACR); 2008. 13 p.

Work Loss Data Institute. Head (trauma, headaches, etc., not including stress & mental disorders). Corpus Christi (TX): Work Loss Data Institute; 2008. 152 p.

Sasser SM, Hunt RC, Sullivent EE, Wald MM, Mitchko J, Jurkovich GJ, Henry MC, Salomone JP, Wang SC, Galli RL, Cooper A, Brown LH, Sattin RW, National Expert Panel on Field Triage, Centers for Disease Control and Prevention. Guidelines for field triage of injured patients. Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009 Jan 23;58(RR-1):1-35. 78

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Keywords

traumatic brain injury, TBI, closed head injury, nonpenetrating head injury, epidural hematoma, subdural hematoma, subarachnoid hemorrhage, SAH, intraventricular hemorrhage, intracranial hemorrhage, intracerebral hemorrhage, ICH, cerebral contusion, coup injury, contrecoup injury, diffuse axonal injury, DAI, generalized brain ischemia, Duret hemorrhage, brain stem injury, brain death, intracranial pressure, ICP, cerebral perfusion pressure, CPP, cerebrospinal fluid, CSF, decompressive craniotomy, motor vehicle collisions, motor vehicle accident, MVCs, contemporary neuromonitoring

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Contributor Information and Disclosures

Author

Leonardo Rangel-Castilla, MD, Staff Physician, Division of Neurosurgery, University of Texas Medical Branch School of Medicine
Leonardo Rangel-Castilla, MD is a member of the following medical societies: American Association of Neurological Surgeons and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

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 and Congress of Neurological Surgeons
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, and Congress of Neurological Surgeons
Disclosure: Nothing to disclose.

Paul Salinas, MD, Resident Physician, Department of Neurosurgery, University of Texas Medical Branch at Galveston
Disclosure: Nothing to disclose.

Medical Editor

Paul L Penar, MD, Professor, Department of Surgery, Division of Neurosurgery, University of Vermont School of Medicine
Paul L Penar, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, and Congress of Neurological Surgeons
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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