S Galbraith

Methods for assessing early characteristics and late outcome after severe head injury have been devised and applied to 700 cases in three countries (Scotland, Netherlands, and USA). There was a close similarity between the initial features of patients in the three series; in spite of differences on organisation of care and in details of management , the mortality was exactly the same in each country. This data bank of cases (which is still being enlarged) can be used for predicting outcome in new cases, and for setting up trials of management.

The incidence of head injury has risen in recent years and now accounts for almost one-third of acute male surgical admissions to the Western Infirmary, Glasgow. A prospective study has established that in Glasgow alcohol is a major associated factor, 62% of males and 27% of females having detectable levels in the blood (greater than 5 mg/100 ml); in these patients the mean level was 193 mg/100 ml in men and 165 mg/100 ml in women. The alcohol level was significantly higher in patients who had had 'a fall under the influence', or had been the victims of an assault, than in those involved in traffic or other accidents. This suggests that alcohol may be an important contributroy cause of head injuries in this city. Depression of the conscious level occurred at blood alcohol levels aroung 200 mg/100 ml, but a significant number of patients in coma had a serious head injury.

CT scan findings, clinical features and intracranial pressure were studied in patients with severe diffuse head injury. Compression of the 3rd ventricle and basal cisterns closely correlated with an intracranial pressure greater than 20 mmHg, with clinical signs of midbrain dysfunctions and worse prognosis. These CT scan findings can indicate whether intracranial pressure monitoring is appropriate.

Deciding which head-injured patients should be transferred to a neurosurgical unit can be difficult. Traditional criteria emphasise the development of deteriorating responsiveness but lead to delayed diagnosis and to avoidable mortality and morbidity. To discover if a more liberal admission policy improved results a study was conducted analysing data collected prospectively from 683 patients who had a traumatic intracranial haematoma evacuated in the Glasgow neurosurgical unit between 1974 and 1980. In the first four years, before the change in policy, mortality was 38% but decreased to 29% afterwards. This reflected a reduction in the proportion of patients who talked after injury but who deteriorated into coma before operation--that is, 31% before the change in policy, 16% afterwards. If the potential benefits of CT scanning in the management of head injuries are to be realised patients must be scanned sooner than in the past. This will usually mean that more patients should go to a neurosurgical unit and that simple criteria for transfer should be established.