Head Injury Follow-up

Updated: Sep 29, 2016
  • Author: David A Olson, MD; Chief Editor: Stephen A Berman, MD, PhD, MBA  more...
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Follow-up

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.

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Further Inpatient Care

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

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Transfer

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

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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%. [149]

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. [150]

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%. [151] 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. [152] 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. [153]

Falls in the elderly are often multifactorial in origin and consequently, solutions are likely to be complex. Nevertheless, random allocation of indepently living elderly patients to a fall-prevention regime of strength and balance training reduced both the number of falls as well as their severity. [154]

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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. [155] Furthermore, coexisting musculoskeletal injuries may impact cognitive testing. For example, collegiate athletes with musculoskeletal injuries performed just as poorly on computerized neuropsychological tests as athletes with concussions. [156]

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. [157] 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 based on the GCS discovered that after 1 year, 26% had moderate disability and 3% had severe disability, but all these patients also had either radiological abnormalities or focal neurological signs, placing them in the more severe range of mild head injuries. [158] A recent review sponsored by the National Institute of Medicine concluded that there is no clear evidence of lasting cognitive impairments attributable to mild closed head injuries. [159]

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. [160, 161]  In addition, return to play is contingent on the resolution of the initial concussion symptoms. [147]

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. [162] 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. [163]  American football, male gender, and young age ranges are associated with this syndrome. [164]

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%). [88]

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. [165]

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. [166]

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. [167]

Posttraumatic headaches

Posttraumatic headaches are common and may occur in 30-90% of patients after a head injury. [168] The alterations in cations, catecholamines, and excitatory amino acids are similar in both migraine and head injury. [169]

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. [170]

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. [46]

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. [171] 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. [172]

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. [173]

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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 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. [174]
  • 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. [61]
  • 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. [175] 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. [176]
  • Overall, patients with traumatic brain injury are 2.23 times more likely to die than their non-injured counterparts. Brain-injured patients' life expectancies are reduced by about 9 years. [177]
  • 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. Furthermore, even after controlling for injury severity and GCS scores, a current study of head-injured elderly motor vehicle accident victims demonstrated more than 3 times the mortality compared with their younger counterparts. [178, 179]  Similar results were recently documented in a study of severely head-injured elders from Norway with 72% attaining an unfavorable outcome, defined as inability to be independent when out of their home environment. [180]
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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. [181]

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 eMedicineHealth's First Aid and Injuries Center, Brain and Nervous System Center, and Eye and Vision Center. Also, see eMedicineHealth's patient education articles Concussion, Dementia in Head Injury, and Black Eye.

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