Prognosis in Patients With Severe Head Injury
Data been collected prospectively on patients with severe head injury—studied in collaboration between Glasgow, Rotterdam, Groningen, and Los Angeles1. This data bank allows detailed analysis of the relationship between early features in the head-injured
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Universities of Glasgow, Groningen, Rotterdam, and Southern California
Prognosis in Patients With Severe Head Injury B. Jennett, G. Teasdale, S. Galbraith, R. Braakman, C. Avezaat, J. Minderhoud, J. Heiden, T. Kurze, G. Murray, and L. Parker Data been collected prospectively on patients with severe head injury-studied in collaboration between Glasgow, Rotterdam, Groningen, and Los Angelesl. This data bank allows detailed analysis of the relationship between early features in the head-injured patient at various stages in the first week after injury, and ultimate outcome. All patients were in coma for at least six hours after injury, although in a third of cases this developed only after a period of relative lucidity. Coma was defined as "no eye-opening, no uttering of words, no obedience to commands", no matter how strong a stimulation was applied. This definition is comparable to that suggested by the Coma Committee of the WFNS-a state of "unrousable unresponsiveness"2. Severity in the early stages after injury has been assessed by clinical criteria: responsiveness on the Glasgow Coma Scale, abnormal motor patterns, pupillary responses, eye movements, and autonomic responses. Results The data bank now contains 1000 cases, and the additional data underline the similarities between severely head-injured patients in the different centres, both in early features (Table 1) and in outcome (Table 2). Even after going into coma, the state of the patients was labile, in particular within the first 24 hours. Thus, at some time during this period almost half of the patients showed an absent or extensor motor response (coma sum 3/4), but in many patients this was only a transient phase, and in the majority of patients some better form of motor responsiveness was observed at some time within the first 24 hours. A similar phenomenon occurs with non-reacting pupils and disordered eye movements (Table 3). Because of this discrepancy, if patients were judged only upon their worst state, an over-pessimistic prognosis would
B. Jennett et al.:
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Table 1. Features in Three Countries Glasgow 593
Netherlands 239
Los Angeles 168
Mean age Lucid interal Intracranial haematoma Extracranial injury
35yrs 32% 54% 32%
32yrs 25% 28% 51%
35yrs 23% 56% 51%
Responsiveness (24 hours best) Coma sum 3/4 Coma sum 5/6/7 Pupils not reacting Eye movements: absent/impaired
17% 52% 19% 45%
20% 55% 29% 37%
21% 66% 31% 40%
Table 2. Outcome at 6 Months
Dead Vegetative Severe disability Moderate disability Good recovery
Glasgow 593
Netherlands 239
Los Angeles 168
48% 2%
50% 2% 7% 15% 26%
50% 5% 14% 19% 12%
10%
18% 23%
Table 3. Frequency of Severe Dysfunction in the First 24 Hours (as % of patients for whom observations available)
Coma scale score 3 or 4 Non-reacting pupils Absent/bad eye movements
Best State
Worst State
176 226 186
467 424 268
19% 23% 23%
49% 44% 34%
be obtained. Thus, 13% of all patients who had a coma sum of 3 or 4 at some period in the first 24 hours were able to make moderate or good recoveries; by c
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