Closed Head Injury Follow-up

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

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).

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Further Inpatient Care

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

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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.

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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).

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Complications

See Secondary injuries.

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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. [88, 89]

In a study of mortality in 44 elderly patients (≥75 years) who underwent an operation for acute subdural hematoma, patients who were independent had a 1-year mortality of 42%, versus 69% for dependent patients (median follow-up, 4.2 yr; range, 2.5 to 6.4 yr). Patients taking antithrombotics had a 56% mortality after the first postoperative year, versus 30% for those not taking antithrombotics. All patients with an admission Glasgow coma scale score of 3-8 died within the first postoperative year if they used antithrombotics or were dependent before the injury. [90]

Patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) who were treated via craniotomy or craniectomy for SDH between 2005 and 2012 were studied for mortality, other adverse outcomes, and length of hospital stay. The most common individual adverse events were death (18% of the patients died within 30 days of surgery) and intubation for more than 48 hours (19%). In total, 34% experienced a serious adverse event other than death, 8% of patients returned to the operating room, and the average hospital length of stay was 9.8 ± 9.9 days. Increased mortality was associated with gangrene, ascites, American Society of Anesthesiologists (ASA) Class 4 or higher, coma, and bleeding disorders. Reduced mortality was associated with age less than 60 years. [91]

A study of patients with chronic subdural hematoma found that neurologic status on admission was the best predictor of outcome. In addition, age, brain atrophy, thickness and density of hematoma, subdural accumulation of air, and antiplatelet and anticoagulant therapy were found to correlate significantly with prognosis. [92]

In a retrospective study of patients with epidural hematoma based on the Nationwide Inpatient Sample (NIS) from 2003 to 2010, 5189 admissions were identified in the database, and incidence was highest in the second decade (33.4%). Median length of stay in the hospital was about 4 days in each year, and in-hospital mortality and complication rate were 3.5% and 2.9%, respectively. [93]

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. [26]

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. [94]

The development and duration of fever is clearly associated with worse prognoses. [21]

The results from one study found that insulin deficiency due to diabetes mellitus (DM) imparts an increased risk for mortality in patients with moderate-to-severe traumatic brain injury (TBI) compared with patients without DM (14.4% versus 8.2% ). [95]

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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.

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