Part Two MEASURING AND MONITORING INJURY · Brain function is particularly difficult to assess,...

Part Two

MEASURING ANDMONITORING INJURY

Introduction

CT scanning has provided a fast, non-invasive anddetailed method of assessing the morphology of braininjury and is now an essential part of any traumamanagement system. CT scanners are increasinglyavailable at the hospital of first contact and connectedto a central trauma center by teleradiology. This hasled to an increase in the speed of diagnosis andtreatment of surgical hematomas, better planning andretrieval, and more discriminating admission policiesfor patients with severe head injury or skull fracture.

Our limited understanding of the pathophysio-logical events that occur after brain injury, and thehigh frequency of secondary delayed neurologicaldeterioration, have stimulated the search for accurate,continuous monitoring techniques, particularly for thefirst days after injury. Some of these techniques arelisted in Table II.1. None of the present techniques areideal, and academic head injury centers continue tosearch for better methods.

The reasons for monitoring the injured brain aresimple:

� to detect harmful pathophysiological events beforethey cause irreversible damage to the brain;

� to allow the type of harmful pathophysiologicalprocess to be diagnosed and effectively treated;

� to provide ‘on-line’ feedback to guide therapydirected at these processes.

In addition they should be non-invasive and prefera-bly cheap.

In general, monitoring techniques may be dividedinto two types – those that assess substrate delivery to

the injured brain and those that assess brain function.Brain function is particularly difficult to assess, sincemost severely head-injured patients are in coma.

Monitoring techniques that aim at providing con-tinuous or near continuous information must bedifferentiated from intermittent measurement tech-niques (e.g. CT scanning) that provide a static imageof the injured brain at intervals. Modern managementclearly uses both techniques.

Duration of monitoring

The optimal duration of monitoring will vary frompatient to patient, depending upon the pathophysio-logical process in question. In a recent large seriesfrom the Medical College of Virginia, the meanduration of ICP monitoring ranged between 5 and 7days. Often it is not practical to continue to monitor apatient until consciousness returns. On the otherhand, it is seldom necessary to continue monitoringonce a patient is able to obey commands; the patientcan then be followed adequately with the neurologicalexam. It is desirable to continue monitoring until ICPis beginning to decline and until cerebrovascularautoregulation has been reestablished. Studies haveshown that autoregulation is generally recovering bythe seventh day after injury and is almost always backto normal for all three physiological stimuli – bloodpressure, PaCO2 and PO2 – by 2 weeks after injury.

In the following chapters, monitoring of ICP, CBF,transcranial Doppler, brain oxygen uptake and elec-trophysiological function are highlighted. Many ofthese techniques are complementary.

144 INTRODUCTION

Table II.1 Advantages and disadvantages of monitoring techniques used for acute brain injury

Method Advantages DisadvantagesApproximate cost(US$; 1995)

Invasiveness/risk

Techniques for assessing substrate delivery

ICP MonitoringVentriculostomy May drain CSF to lower

ICP; may calculate CPP;may use waveformanalysis and measure PVI.

Highest infection risk(5–10%).Hemorrhage risk ~ 0.5%.May be difficult to insert.

450 ++++

Parenchymalelectronic sensorse.g. Camino,Codman

Easy to insert and use.Lower infection/hemorrhage risk; may usewaveform analysis.

Cannot drain CSF.Difficult to recalibrate.

Camino 6500Each sensor 485

++++

CBF flow probesThermal diffusion orlaser Doppler

May select the brain regionto monitor. May guidehyperventilation therapy.

Measures relativechange, not absoluteflow. Thermal diffusionrequires a craniotomy foroptimal insertion.

Instrument4700–16 500Sensor 300

+++

AVDO2

Jugular catheter May guidehyperventilation andpressor therapy.

Intermittent. Indirectmeasure of brain O2extraction and flow.Contaminated byextracranial venous flow.

Catheter ≈ 100Sample analysis500/day

++

Fiberoptic sensor e.g.Oxymetrix

Continuous. Inaccurate in up to 40%of readings.

28 000 (instrument)765 (each sensor)

Transcutaneousnear-infraredspectroscopy (NIRS)

Correlates well with brainO2 (Hammamatsu system)

Accuracy/specificity notyet proven in trauma.Not reliable whenintracranial bleeding ispresent.

50 000(Hammamatsusystem)

–

Brain oxygenmeasurement

Reflects ‘true’ substratedelivery: accurate. (Maymeasure, CO2, pH andtemperature).

Fragile; microregional. 20 000 (system)300 (each sensor)

+++

TranscranialDoppler

Wave-form analysis mayindicate high ICP. Detectsvasospasm in ~ 28%.

Qualitative; difficult tofix the head; operator-dependent. Significanceunclear.

15 000–30 000(system)

–

Microdialysis Many analytes availablefor analysis; highlysensitive.

Not ‘on-line’; requiresHPLC for analysis; labor-intensive.

20 000 (system)26 000 (HPLC)150 (probes)

++

Techniques for assessing brain function

Neurologicalobservation (comascale)

Most sensitive and specificindicator of brain function.

Lost in coma; may bepreserved while focaldamage is occurring, in‘silent’ areas?

Nursing time –

EEG/EEGSpectral array

Sensitive, even in coma;indicates seizures, evenwhen patient is on musclerelaxants.Useful in prognosis.

Difficult to interpret;non-specific; significanceuncertain.

system 20 000–80 000 –

Evoked potentials Loss of evoked potentialscorrelates well with death/vegetative outcome. Usefulfor prognosis. May detectfocal deficit or spinalinjuries.

Not a useful guide totherapy. Operator-dependent.

system40 000–100 000

–

8 CLINICAL EXAMINATIONAND GRADING

Donald A. Simpson

8.1 Introduction8.1.1 ROLES AND LIMITATIONS OF CLINICALEXAMINATION

Severe closed head injuries are now routinely investi-gated by early computed tomography (CT), whichvisualizes most pathological lesions of immediatesurgical importance. It is also routine practice tomonitor the intracranial pressure and other para-meters of cerebral physiology, providing objectivedata to control the use of artificial ventilation andother forms of conservative therapy. It is thereforelegitimate to ask what now are the roles of clinicalneurology in the management of head injuries ingeneral, and severe head injuries in particular.

The initial clinical evaluation is still crucially impor-tant, in triage and as a baseline in assessing progress.The prognosis depends to a large extent on thefindings of the initial examination, and the neuro-logical status at a specified time after injury is widelyused as a measure of head injury severity. Moreover,valuable as they are, the neuroradiological findingsmust be interpreted in the light of the clinical findings.Thus clinical examination of the head-injured patientcontinues to be indispensable. But modern strategiesof severe closed head injury management havebrought one very important change in the nature ofthis examination: because it is often wise to performendotracheal intubation as soon as possible, the firstneurological examination is now usually performed atthe accident site or in the emergency room, and oftenby someone with no special training in neurology.This means that the paramedic, the intensivist and theemergency physician must be competent in performingan appropriate neurological examination before intu-bation and respiratory paralysis are instituted.

This does not mean that all the rites of medicalneurology should be taught to everyone who mayintubate an unconscious patient; it means that suchpersons must be skilled in making a few basicneurological observations and recording them accu-

rately. These observations are usually done in twophases. In the primary survey, the conscious leveland the pupillary reactions are tested (Table 8.1). Ifresuscitation includes endotracheal intubation, limbmovements should be quickly tested before a musclerelaxant is given. In the secondary survey, done afterresuscitation, these findings are checked, and inaddition the examiner assesses limb motor functionand, if possible, vision and cutaneous sensation(Table 8.2).

A definitive or tertiary examination by a surgicalneurologist retains its value in the late evaluation of asevere head injury. It is often done in collaborationwith a neuropsychologist. This definitive examinationconsiders especially the neurological functions thatcannot be tested in the unconscious patient, notablyspeech, mentality, cognitive functions, smell, vision,hearing and sensorimotor function. The definitiveassessment also includes a retrospective judgment ofthe duration of unconsciousness and amnesia (seebelow). The long-term effects of severe head injury areoutside the scope of this book, but the care of a head-injured person should not be compartmentalized:evaluation – like counseling – is a continuous processand the early findings bear important relationshipswith what is found as the patient emerges from coma.

8.1.2 THE HISTORY

The history retains its importance in the evaluation ofsevere head injury. It is usually obtained from eye-witnesses of the accident and from the family or friendsof the injured person. The site and cause of the impactmay give clues to the pathology; blunt weapons, fallsand road crashes show more or less characteristicpatterns of intracranial damage. The sequence ofevents after impact may distinguish between primarybrain damage and secondary cerebral compression.The health before injury may be relevant. Medicalertbracelets identify serious illness or medication, and areoften helpful in unconscious patients. However people

Head Injury. Edited by Peter Reilly and Ross Bullock. Published in 1997 by Chapman & Hall, London. ISBN 0 412 58540 5

146 CLINICAL EXAMINATION AND GRADING

with serious illnesses may refuse to wear these,especially if the disease is seen as a stigma.

8.2 The initial examination

8.2.1 CONSCIOUS LEVEL

For the clinician, this is the best empirical measure ofimpaired cerebral function after closed head injury.

Impairment of consciousness is stratified in terms ofthe responses to external stimuli, and serial records ofthese responses are important in head injury manage-ment. The early postinjury conscious level may bepreserved prior to secondary deterioration; this meansa much better prognosis and also implies that ahematoma may be present. Though the role of nursingrecords in the early detection of cerebral compressionhas been diminished by the advent of CT scanning,serial progress records of the conscious level remainstandard practice in head-injury observation, espe-cially when the head injury initially appears to be lessserious (Figure 8.1).

The conscious level is also a valuable index of injuryseverity. In early evaluation, the depth of impairmentof consciousness can be used as a measure of cerebralimpairment, provided that the dimension of time afterimpact is taken into account and provided thatconfounding causes of impaired consciousness, suchas ethanol, drugs or hypoxia, can be excluded. In lateevaluation, a retrospective estimate of the duration ofloss of consciousness can be used as a definitivemeasure of cerebral injury, though with certain reser-vations that are discussed below. For both purposes, itis necessary to define and quantify impairments ofconsciousness.

8.2.2 COMA SCALES

In 1941, a wartime committee of British clinicalneuroscientists recognized the need for a standardizedterminology for states of impaired consciousness afterhead injury, and published a glossary of descriptiveterms. This committee included three brilliant neu-rosurgeons – Hugh Cairns, Geoffrey Jefferson and

Table 8.1 The primary survey. The A-B-C-D-E summary is a mnemonic for the early evaluation of severe trauma. Itgives basic data on the neurological status after head and/or spinal injury (after American College of SurgeonsCommittee on Trauma, 1993)

Survey Check Note, record and correct

A Airway Patent?Noisy?

Obstruction

B Breathing Effective? Rate and depthChest movementsAir entryCyanosis

C Circulation Adequate? Pulse rate and volumeSkin colorCapillary returnHemorrhageBlood pressure

D Disability(= neurological status)

Normal? Conscious level – AVPU or preferably GCSPupillary light reactions

E Exposure(= undress)

Other injuries? Limb movements – on command or on painful stimulus

Table 8.2 The secondary survey. This is done afterresuscitation. It includes a minimal neurologicalexamination, which should be within the competence ofany practitioner undertaking the early management ofsevere trauma. It commonly leads at once to specialinvestigations e.g. X-ray of the cervical spine, CT scan,blood screen for ethanol and other drugs

History From patient and from observers

Reassessment ofvital signs

As in primary survey

External signs ofinjury

Inspection and palpation of scalp,face, eyes and neck

Conscious level GCS is repeated; this entailsevaluation of speech and record ofairway

Vision Pupils: evaluation of size, symmetryand light reactionAcuities and fields: done by coveringeach eye and checking visualperception of examiner’s face

Limb weakness –lateralized orlocalized?

Detected from spontaneousmovement, movement on commands,movement on finger- and toenailpressure

THE INITIAL EXAMINATION 147

Norman Dott. The committee had great authority andthe terminology was widely accepted. Although theoriginal publication (Medical Research Council BrainInjuries Committee, 1941) did not set out a gradedhierarchy of levels of impaired consciousness, the

recommended terms were easily used to formulatesuch a hierarchy, and appeared in graphs of clinicalprogress in Rowbotham’s (1945) very influential text-book (Table 8.3). Those who used this system soonfound that it was often misleading in communication

Figure 8.1 Neurological observation sheet. The record shows rapid deterioration of the consciousness level withappearance of ipsilateral pupillary dilatation and a contralateral hemiparesis. The GCS score falls from 15 to 5. Since theindications for action were evident by 15.30 h at latest, the record would imply unacceptable management! (Hypotheticalcase recorded on the 15-point version of the Glasgow Coma Scale, by courtesy of Mr M. Fearnside.)


between staff members without neurological training,and many neurosurgeons tried to formulate scales thatused explicit grades of response to specified stimuli,given in simple descriptive terms. It was from suchendeavors that Teasdale and Jennett (1974) devised theGlasgow Coma Scale (GCS).

This scale has been in use for more than 20 years,and its value is so widely accepted that a descriptionmay seem superfluous. However, the scale has itscritics, and its application has changed somewhatsince it was first reported. The authors describedhierarchies in the levels of response for movement ofthe upper limb, verbal or vocal utterance and eyeopening (Table 8.4). In their first paper, they listed onlyfive levels of motor response; they noted that it ispossible to distinguish normal and abnormal limbflexion, but concluded that the distinction was notappropriate for general clinical use. As a painfulstimulus, nailbed pressure with a pencil was advised.For verbal responses and for eye opening, the scaleprovided five and four levels respectively. In describ-ing the painful stimulus for eliciting eye opening, theauthors specifically warned against using supraorbitalpressure or retromandibular pressure, as these stimulimay evoke eye closure. This warning has not alwaysbeen heeded. Although the value of the scale as ameans of communication between different hospitalswas emphasized, no attempt was made in this paperto give the findings in an aggregated score. Tests ofinter-rater accord were later reported, and showedreasonably close agreement in evaluations by nurses,neurosurgeons and other medical practitioners (Teas-dale, Knill-Jones and Jennett, 1974; Teasdale, Knill-Jones and Van der Sande, 1978). Similar tests haveshown good agreement between ratings by emergencyphysicians and paramedics(Menegazzi et al., 1993).

In later papers, the authors formulated six levels ofmotor responses by including the distinction betweenabnormal or spastic flexion and flexor withdrawal(Teasdale and Jennett, 1976; Jennett et al., 1977) though

Table 8.3 Depth of unconsciousness, simplified fromMedical Research Council Brain Injuries Committee, 1941.This terminology for post-traumatic impairments ofconsciousness is now only of historical interest: it hashowever influenced later thinking (Starmark, 1988)

Coma Absolute unconsciousness, judged byabsence of any psychologicallyunderstandable response to externalstimuli or inner needPrimitive reflexes may or may not bepresent

Semicoma Psychologically understandable responsesare elicited only by painful or otherdisagreeable stimuliPrimitive reflexes present

Confusion Impaired capacity to think clearly andrapidly, to perceive and remember currentstimuli; also disorientation

Severe The patient occasionally responds tosimple commands, if necessary reinforcedby gestures, e.g. ‘put out your tongue’,‘take my hand’

Moderate The patient, though out of touch with hissurroundings, can be got to give relevantanswers to simple questions, e.g. ‘whatwork do you do?’, ‘where do you live?’

Mild Confused but capable of coherentconversation and appropriate behaviour

Table 8.4 Variant forms of the Glasgow Coma Scale. In their first publication, Teasdale and Jennett (1974) did notdiscuss the use of a summated score; in later publications, the 15-point version of the GCS has been used in givingComa Score

14-point scale(Teasdale and Jennett, 1974)

15-point scale(Teasdale and Jennett, 1976)

Pediatric scale(Simpson and Reilly, 1982)

Eye opening Spontaneous 4To sound 3To pain 2None 1

The same The same

Best verbal response Orientated 5Confused 4Inappropriate 3Incomprehensible 2None 1

The same Orientated 5Words 4Vocal sounds 3Cries 2None 1

Best motor response Obeying 5Localizing 4Flexing 3Extending 2None 1

Obeys commands 6Localizes pain 5Flexion–withdrawal 4Flexion–abnormal 3Extension 2None 1

Obeys commands 5Localizes pain 4Flexion 3Extension 2None 1

Maximum sum 14 15 14


they recognized that the original simpler scale might bepreferable for clinical purposes (Jennett and Teasdale,1981). Abnormal flexion was recorded if there were anytwo of the following: stereotyped flexion posture,extreme wrist flexion, abduction of the upper arm andfisting of the fingers over the thumb. This additionaldistinction made the GCS somewhat more demandingfor the less skilled observer, but increased its analyticpower, especially in severe closed head injuries; somuch so that Jagger et al. (1984) argued that, as aprognostic guide, the Glasgow motor score alone wasmore informative, at least in comatose patients.

Teasdale and Jennett (1976) also recommended theuse of the total score (summed scores for eye opening,verbal and motor responses) for comparison of headinjury severity between patients and between series,and as a rough definition of coma. A patient giving noverbal response, not obeying commands and notopening the eyes was judged to be in coma; by thisdefinition, all patients showing a GCS score of 7 or lesswere comatose, and so were the majority (53%) of thosewith GCS score 8, when the maximum score was 15.

The GCS found many supporters, but also a fewcritics and skeptics. Some critics were clinicians whoalready used a measure of consciousness of somekind, and were reluctant to discard it; others devisedsupposedly more convenient variants of the GCS tomeet local needs. Other criticisms related to theadmitted limitations of the GCS in cases with periorbi-tal swelling, which may eliminate the eye-openingresponse, or endotracheal intubation, which elim-inates the verbal response. Starmark, Holmgren andStålhammer (1988) reviewed 96 head injury studiespublished in the period 1983–1985; in these, GCS datawere interpreted or aggregated in many ways, andother methods of grading consciousness were used in23 papers (24%). Starmark et al. (1988) compared theSwedish form of the GCS (using retromandibularpressure and nailbed pressure as painful stimuli) withtheir own Reaction Level Scale (RLS 85; Table 8.5) andfound better inter-rater agreement with the RLS 85;however, Johnstone et al. (1993) could find no sig-nificant differences between these scales in discrim-inating between grades of head injury severity, though

Table 8.5 The Swedish Reaction Scale (RLS85); in the manual for this scale, the responses are further explained bydiagrams (Source: after Starmark et al., 1988, with simplification of the explanatory column. The RLS85 Manual ispublished by Acta Neurochirurgica (Wien).)

Mentally responsive

1. Alert. No delay in response Alert: not drowsy, orientated (intubated patient: no signs of delay inreaction)

2. Drowsy or confused. Responsive tolight stimulation (verbal or touch)

Drowsy: the patients seems drowsy and shows delay in reactionConfused: the patient gives the wrong answer to at least one of threequestions: What is your name? Where are you? What is the year and themonth?

3. Very drowsy or confused.Responsive to strong stimulation(loud verbal, shaking, pain)

Arousable: performs at least one of the following functions: oral responsewith words; orientating eye movements; obeying commands; warding offpain

Mentally unresponsive

4. Unconscious. Localizes but doesnot ward off pain

Unconscious. No mental activity. Cannot perform any of the activities listedabove for ‘mentally responsive’Localizes pain. Examination is done in supine position: retromandibularpressure elicits movement of arm above chin level; nailbed pressure elicitsmovement of other hand across the midline

5. Unconscious. Withdrawingmovements to pain

Withdrawing movements. On retromandibular pressure patient turns faceaway; on nailbed pressure, patient does not localize the pain but makesclear withdrawing movements

6. Unconscious. Stereotyped flexionmovements to pain

Stereotyped flexion movements. On retromandibular pressure or onnailbed pressure, patient makes slow and mechanical flexion movements ofelbows and wrists but no localizing or withdrawing movements

7. Unconscious. Stereotypedextension movements to pain

Stereotyped extension movements. On retromandibular pressure or onnailbed pressure, patient makes extension movements, straightening arms orlegs. No flexion is seen; if both flexion and extension are seen, the betterresponse (i.e. flexion) is recorded

8. Unconscious. No response to pain No response to pain. Repeated strong pain from retromandibular or nailbedpressure gives no movement in arms, legs or face


the RLS 85 was regarded as a simpler procedure. TheGCS has been in service for more than 20 years, and itshould now be possible to give an appraisal of thepresent status of the GCS in the three roles for whichit has been used: neurological observation, prognosisand severity grading.

For the first purpose, it seems that most nurses,ambulance officers and surgeons accept the scale as ameans of detecting changes in the conscious level andas a convenient currency in communication. In somecenters, other in-house coma scales are used forsupposedly greater simplicity, but in general the GCShas been found to be very serviceable. Many standardtextbooks recommend the GCS. The American Collegeof Surgeons Committee on Trauma (1993), in itsmanual Advanced Trauma Life Support Program forPhysicians, sanctions the simpler non-quantitativeAVPU variant, which has four levels – alert (A),responsive to vocal stimuli (V), responsive to pain (P),and unresponsive (U). The AVPU scale is used in theinitial assessment, but the GCS is recommended in thesecondary assessment.

In modern surgical practice, the chief clinical usesof the GCS are in the early evaluation of the primaryeffects of a head impact, in routine monitoring of lesssevere head injuries to detect changes due to compli-cations and in monitoring the progress of recovery.The relative merits of the 14- and 15-point scales havereceived little discussion in these contexts. In 1990, aquestionnaire was sent to senior Australasian neu-rosurgeons and, of the minority who responded, sevenout of 11 preferred the 14-point scale for clinical use.However, the 15-point scale is internationally acceptedfor research studies and this is a powerful argumentfor using it routinely.

It is less easy to determine the status of the GCSin prognosis. The depth of coma is certainly onefactor in clinical decisions on head injury treatment.Jennett (1992) has reviewed the circumstances inwhich continued treatment of a head-injured personis ‘futile or disproportionately burdensome’ and inthis review age and depth of coma stand out as thechief predictors of death. In an earlier study of 1000severe head injuries, Jennett et al. (1979) had shownthe prognostic value of GCS summated scores: deathor vegetative survival was the fate of 87% of thosewhose best score in the first 24 hours was 3/4,whereas these bad outcomes were recorded in only53% of those with scores of 5/6/7. To exclude theeffects of alcohol, hypoxia and other confoundingfactors, this study included only cases remaining incoma for more than 6 hours. If, as is now often thecase, initial resuscitation includes immediate endo-tracheal intubation and paralysis, the effects of theseconfounding factors on conscious level cannotalways be excluded. The ethanol level can and

should be measured; Jagger et al. (1984) have shownthat over a level of 0.20%, ethanol may significantlydepress the GCS score, though there is much individ-ual variation in this effect. But even when allowanceis made for intoxication, the initial GCS level has tobe viewed with reserve as a prognostic factor and, indetermining whether to cease supportive treatment,the clinician will usually rely on repeated evaluationsof the coma level after temporary cessation of respi-ratory paralysis and sedation. In establishing thecoma scale, and in subjecting it to rigorous statisticalanalysis, Teasdale, Jennett and colleagues made avery great contribution to clinical neuroscience, andtheir work has enduring value. But, as these authorspresciently forecasted, newer methods of therapyhave reduced the availability of GCS scores forprognostic purposes.

The value of the GCS as a measure of head injuryseverity is considered below.

8.2.3 PEDIATRIC COMA SCALES

It is not easy to assess the consciousness level ininfants and young children, and mistakes are oftenmade. Sometimes the severity of a head impact isoverestimated, but the converse error is much com-moner: because an injured infant cries or whimpers, itis thought to be fully ‘conscious’ and serious braindamage may be overlooked.

The verbal and motor responses that indicate fullconsciousness in the GCS are obviously not achievableby preverbal infants. Even after speech is attained, afrightened but fully conscious child may withholdspeech or cooperation. There have therefore beenmany attempts to devise a scale of consciousnessappropriate to the first 5 years of life. These have beenreviewed by Yager, Johnston and Seshia (1990) andSimpson et al. (1991).

Pediatricians and neurological nurses are wellaware of the subtlety and scope of preverbal respon-ses, and some of the reported scales try to quantifythese. Thus, Seshia, Seshia and Sachdevan (1977)devised an elaborate grading that tested social, adap-tive, vocal and motor responses, and also suck/coughresponses, both spontaneous and stimulus-evoked;each was given a 0–4 value. Hahn et al. (1988) deviseda scale using the Glasgow scale for eye opening andmotor responses but with a more complex range ofverbal responses, including subscores for smiling, eyeorientation, consolability and interaction. Simpsonand Reilly (1982) preferred a much simpler system,directly based on the original GCS but with age-related norms for the verbal and motor responses. Thisscale expresses the concept that the range of responsesin head-injured infants and young children is nar-rower than is the case over the age of 4 years. Norms


(Figure 8.2) for best anticipated responses at birth, 6months, 1 year, 2 years and 3–5 years are derived fromaccepted developmental milestones (Reilly et al.,1988); actual responses are recorded in ward chartsidentical with the 14-point GCS except in the verbalscale, in which minor changes have been made toallow a simple grading of preverbal responses (Table8.4). The Paediatric Glasgow Coma Scale (PGCS),was independently compared by Yager, Johnston andSeshia (1990) with five other systems of quantifyingthe consciousness level in early life, and found to beone of the two best from the viewpoint of observerdisagreement (< 0.10). We believe that the PGCS, in itssimplicity and its close resemblance to the GCS, iswell adapted to hospital use, though some instructionis needed for nurses used to the adult scale. A videofilm has been made for this purpose. In Melbourne, G.Klug (personal communication) has successfullydeveloped a 15-point version of the PGCS, in whichabnormal limb flexion is recognized as in the adultscale.

As a prognostic tool, the PGCS has not been fullytested. In a series of 23 infants and young childrenwith impaired consciousness, bad outcomes wererecorded in six of seven cases with summated PGCSscores of 3/4, in three of five in the range 5/6 and innone of 11 cases in the range 7/8 (Simpson et al., 1991).At the lower levels, the PGCS is based on observationsidentical with those recorded in the adult scale, and it

seems likely that the predictive value is similar. Hofer(1993) compared outcomes with scores derived fromthe standard 15-point adult scale in a sample of 41children (age range 2–17 years, mean age 8.8 years)and found that the lowest GCS scores were strongpredictors of death. However, this study excludedinfants and included only two children less than 4years old; moreover, it related to observations made 24hours after operation. There is need for furtherresearch on the prognostic significance of post-trau-matic coma in infants.

8.2.4 THE PUPILS

Pupillary size, shape and reactions are routinelyrecorded at the initial examination, and routinelychecked at specified intervals thereafter. If the pupil-lary light reflex is impaired on one side, the consen-sual light reflex is tested to exclude an optic nervelesion. Even iconoclastic clinicians approve these time-hallowed practices, but one must nevertheless askwhat may be learned from them.

Pupillary abnormalities may be bilateral or uni-lateral; they may be present from the time of injury(Figure 8.3(a)), or may appear after an interval of time.If the initial examination shows that both pupils arewidely dilated, and if there is no reaction to a stronglight – not always available in an emergency room! –then the pathological basis may be an irreparable

Figure 8.2 Norms in the Paediatric Glasgow Coma Scale (PGCS). The expected norms for successive age ranges are set outon a standard ward chart, which shows the modifications of the best verbal responses used in the PGCS. In teaching the useof this scale, it is emphasized that actual performance is often better than the expected norms: many children in the 3–5 yearrange will demonstrate awareness of place or personal relations.If necessary, a standard adult scale can be used, but it mustthen be emphasized that adult performance is not to be expected and the record should show what responses are actuallyelicited.


primary midbrain lesion or advanced bilateral trans-tentorial herniation. There are, however, other causes.The pupils may be fixed and dilated in the aftermathof an epileptic fit, or from inadequate cerebral perfu-sion (Narayan, 1989), or from local trauma to the irisor its innervation on both sides, or from the use of amydriatic to view the fundi, a practice to be prohibitedin the early period after trauma. (Homatropine wasthe cause of dilated fixed pupils in an injuredmotorcyclist admitted in coma after visiting anophthalmologist, whose use of this mydriatic possiblycaused the accident as well as confusing the diag-nosis.) In general, the finding of bilateral fixed dilatedpupils soon after injury is a very adverse sign, and theappearance of this sign after initial normality oftenindicates irreversible cerebral compression. However,the finding must be interpreted in its context and withregard to other findings.

Bilateral fixed pupils of normal shape and sizemay indicate a midbrain lesion; bilateral sluggishpupils associated with ptosis and impaired upwardgaze are an almost pathognomonic sign of central orposterior transtentorial herniation. Bilateral opticnerve injury may give bilateral fixed or sluggishpupils, sometimes with pupillary escape, and thisshould be remembered especially in head injury froma frontal impact; in such cases, the pupils typicallyshow spontaneous fluctuation (hippus) in diameter.Bilateral small pupils, often appearing fixed, are aclassical sign of a pontine lesion. This is a relativelyrare finding in closed head injuries. Large doses of anopiate give similar appearances; in many intensivecare units, morphia is infused to control the reflexresponses of intubated patients, but in the doses nowused the pupillary reactions are usually well pre-served, though the diameters may be small. In deepbarbiturate coma, the pupils become fixed and non-reactive.

Previous neurological disease may be associatedwith bilateral or unilateral pupillary abnormalities.Neurosyphilis was the confusing cause of small fixedpupils in a workman who fell from a scaffold andsustained compound skull fractures. The sluggishtonic pupils of Holmes–Adie syndrome could bemisleading, and it should be kept in mind that tendonareflexia is not an invariable finding in this condition(Bacon and Smith, 1993).

Unilateral dilatation and loss of light reflex in onepupil commonly means a third-nerve paralysis, oftenaccompanied by ptosis and a divergent squint (Figure8.3(a)). This may be a primary effect of the initial headimpact (Heinze, 1960), as a traction injury of the nerveor from damage in the skull base or orbit. Delayedonset of a third-nerve paralysis is of course theclassical sign of lateral transtentorial herniation. Inmodern practice this is most often due to an acute

(a)

(b)

(c)

Figure 8.3 Oculomotor paralysis. A young girl was admit-ted in coma after a road accident. (a) The left pupil wasdilated (5 mm) and fixed to light. The right pupil wassmaller (3 mm) but varied in diameter; initially there was nolight reaction, but later this pupil reacted sluggishly to light.(b) 4 weeks later, rotation of the head to the left and rightelicited a small change in the deviation of the right eye; theleft eye did not move (positive horizontal oculocephalicresponse in association with left third-nerve paralysis).(c) Flexion and extension of the head elicited no change inthe position of the eyes (absent vertical oculocephalicresponse). Photographs reproduced with permission.


subdural hematoma or massive hemispheric swelling;extradural hematomas are now commonly diagnosedbefore this dangerous complication has developed.Jones et al. (1993) studied a series of 366 cases ofextradural hemorrhage treated by a single neurosurg-ical service in a 35-year period and found that beforethe advent of CT scanning, pupillary abnormalitieswere recorded in 70.4%, but were recorded in only34.3% of those treated in recent years.

A unilateral fixed pupil of normal or fluctuatingsize may be due to an optic nerve lesion; consensualtesting will usually establish this diagnosis. A fixedpupil of large or normal size may result from traumato the iris and/or ciliary body; other signs of a localimpact may or may not be detectable. A moreobvious cause of a unilateral fixed pupil is a pros-thetic eye.

Irregularities of pupil shape are not uncommon interminal stages of cerebral compression; the mecha-nism is uncertain. Marshall et al. (1983a) have drawnattention to the finding of an oval pupil, ofteneccentric, as an early sign of transtentorial herniation(Figure 8.4). An ectopic pupil (corectopia) may also bethe result of ocular injury, sometimes long-standing; ina recent case of severe head injury, relatives hadknown of the abnormal pupil for many years, but hadnot been questioned about it until its diagnosticsignificance was discussed.

In view of the clinical importance attached to thepupillary light reflex, it might be expected that itsprognostic significance would be substantial. This isindeed so in certain categories of head injury, notablyextradural hematomas; in the study by Jones et al.(1993) quoted above, death or persistent vegetativestates were recorded in 8.3% of cases presenting withnormal pupils, but in 26.9% of those with a pupillaryabnormality (p = 0.0002). In using the pupils as a

general prognostic factor for outcome after severehead impact, difficulties arise from the great diversityof pupillary abnormalities and their variable sig-nificance. Nevertheless, Choi et al. (1988) concludedthat the pupillary light response was one of the threemost accurate predictors of final outcome, the othersbeing age and GCS motor score. In this analysis, theseauthors recognized three grades of pupillary responseon admission: bilaterally absent, unilaterally absent,and normal. Braakman et al. (1980) used a similargrading, but selected the best state of the pupils in thefirst 24 hours as the prognostic factor: where bothreacted, the mortality rate was 29%, rising to 54%when only one reacted and to 90% when both werefixed.

Pupillary size has received less attention. In thehope of earlier diagnosis of intracranial mass lesions,Chesnut et al. (1994) considered pupillary inequality,irrespective of reaction to light, in a series of 608comatose head injuries. They found that inequality ofmore than 1 mm was present in 35% of thesepatients; when present, this inequality indicated thepresence of an intracranial mass lesion in only 30%– not always ipsilateral and not always an extracere-bral clot. Greater asymmetry (more than 3 mm) wasmore often associated with a mass lesion; never-theless, in more than half the cases with this degreeof asymmetry no such association was found. Com-menting on this study, Narayan (1994) drew theconclusion that pupillary inequality is an unreliablesign and no substitute for routine early CT scanningin patients with severe head injury. Nevertheless,pupillary size and reactivity to light are valuablesigns if taken in context, both in diagnosis and inprognosis.

Pupillary testing is often made impossible byorbital swelling, and this emphasizes the importance

(a) (b)Figure 8.4 Oval pupil. A young man was admitted in coma after a road accident.On admission, the left pupil was dilated(7 mm) and fixed to light. The right pupil was smaller (2–3 mm) and also fixed. (a) 10 weeks after injury, the left pupil wasfixed to light as a result of a third-nerve paralysis. The right eye was deviated down and was abducted. (b) The right pupilwas oval in shape, and reacted sluggishly to light. Photographs reproduced with permission.


of accurate early examination and recording beforeswelling is established. A slovenly initial examina-tion may miss an optic nerve injury, which may thenbe detected days later when the swelling subsides.Desmarres’s eyelid retractors sometimes allow expo-sure of an otherwise inaccessible pupil, but shouldbe used with great caution to avoid cornealabrasion.

8.2.5 EYE MOVEMENTS

In the routine neurological examination of the uncon-scious patient, spontaneous eye movements should benoted. If there are none, the oculocephalic reflexes aretested by rotating the head fully in the horizontal andvertical planes – the oculocephalic or doll’s eye test(Figure 8.3(b), (c)). This is done only when a cervicalspinal injury has been excluded by adequate radio-graphs demonstrating all vertebrae including C7. Thefindings relate to the functional integrity of themidbrain, the pons and the third, fourth and sixthcranial nerves. Thus, spontaneous roving eyes withparallel visual axes suggest normal central andperipheral innervation of the extraocular muscles.Lesions of the third and sixth cranial nerves show upas limitation of eye movements effected by theparalyzed muscles. The fourth nerve is untestable inthe unconscious patient. Forced downward oculardeviation suggests a midbrain lesion. Absence ofupward movement (vertical oculocephalic reflex) hasthe same significance, but may be hard to elicit in aconvincing manner in unconscious patients. Forcedlateral gaze suggests an irritative lesion which may bein the brain stem or in the supratentorial brain;absence of lateral gaze may indicate a paralytic lesionin the same sites. Vertical divergence of the visual axes(skew deviation) is usually taken to mean a pontinelesion.

In addition to their localizing value, the eye move-ments have been considered as indices of head-injuryseverity. Visual fixation and tracking are preserved inrelatively mild injuries; the capacity to fix on a targetand to follow it is a favorable finding, and is especiallyuseful in examining a preverbal infant or an aphasic atany age. Spontaneous roving eye movements usuallyindicate a milder impairment of consciousness, in theGCS range 7/8 or better. At the other end of theseverity spectrum, absence of eye movements is anominous finding. Absence of eye movements onirrigating the external auditory canal with up to100 ml ice-cold water (oculovestibular reflex) is indica-tive of profound brain-stem failure and is one of theaccepted criteria of brain death (Walker, 1985). The testshould not be done if there has been anything tosuggest a cranioaural fistula, such as cerebrospinalfluid otorrhea, intracranial air or a middle fossa skull-

base fracture. However, between these extremes ofseverity, there are many ill-defined disturbances of eyemovement, and it is questionable whether these havemuch if any diagnostic or prognostic meaning.

Jennett et al. (1977) constructed a composite score foreye movements, but this has not been widely used.From Liege, Born et al. (1982) have reported on acomposite coma scale combining the 15-point GCSwith a five-point reflex scale. In the reflex scale,cephalic reflexes are ordered in a hierarchy corre-sponding to their supposed clinical significance as ameasure of rostrocaudal brain-stem function (Table8.6). The fronto-orbital blink reflex is elicited by a lighttap on the glabella. The pupillary light reflex and theoculocephalic reflexes are elicited as described above.If a cervical spinal injury makes head rotation danger-ous, the oculovestibular reflexes are obtained by auralirrigation with iced water – bilaterally for vertical eyemovement, unilaterally for horizontal movement. Theoculocardiac reflex is obtained by pressure on theglobe, failure to demonstrate slowing of heart ratebeing the lowest level in the 0–5 reflex scale. The sumof the GCS score and the reflex score is termed theGlasgow–Liege (GLS) score. Born et al. (1987) haveconfirmed good inter-rater agreement for the reflexscale. In a comparison of the predictive value of thereflex score with the motor component of the GCS insevere head injuries, Born (1988) found that, in thefirst 24 hours, the reflex score is superior as aprognostic tool. However, in surviving cases, thereflex score usually returns to normal within 2 weeks,even in patients destined to be severely disabled,whereas the GCS motor score tends to remain low forlonger periods, even in cases showing a favorableoutcome. This interesting composite scale has notreceived as much attention as it deserves, perhapsbecause two of the reflexes – the fronto-orbital and thevertical oculocephalic reflex – are not in general use inmost neurosurgical centers.

8.2.6 FUNDI

Fundal abnormalities are not usually of great impor-tance in the early management of severe head injuries,and the examination is often difficult: the pupils may

Table 8.6 Liege Reflex Scale. (Source: After Born et al. 1982)

Brain-stem reflexes Score

Fronto-orbicular 5Vertical oculocephalic 4Pupillary light 3Horizontal oculocephalic 2Oculocardiac 1No response 0


be small, there may be orbital swelling, and the use ofcorneal lubricants is often a further impediment. Thereis however some diagnostic yield from early examina-tion of the fundi. The finding of retinal hemorrhagesmay indicate a period of sudden increase in intra-cranial pressure and massive intraocular bleedingmay be a threat to vision. In infants, retinal hemorrh-ages are often due to child abuse, though this is by nomeans a specific association (Duhaime et al., 1992).The diagnosis of child abuse is of such importancethat it may be justifiable to use a mydriatic forfundoscopy in head-injured infants – though onlyafter a CT scan has been done. Early fundoscopy alsogives a baseline against which later possibly abnormalfindings can be evaluated. Papilledema is not acommon finding in severe head injury: Selhorst et al.(1985) found swollen discs in only 15/426 (3.5%) cases.When papilledema does occur, it is usually not gross,and knowledge that the discs were previously normalcan be helpful in deciding on the significance ofindistinct disc margins. This is true also of the lateappearance of optic disc pallor from nerve injury.

8.2.7 LIMB MOVEMENTS AND REFLEXES

Spontaneous and evoked limb movements are studiedas part of the GCS examination. This records the bestmotor response; less good responses are also note-worthy, since asymmetrical or localized impairment ofmovement may reveal a hemiparesis, monoparesis,paraparesis or limb fracture.

Muscle tone is assessed after inspection, by puttingthe limbs through a full range of passive movement –keeping the possibility of a long bone fracture in mind.The tendon reflexes have very little value in thediagnosis of acute cerebral injuries, but localizedabsence of tendon jerks may disclose a nerve injury.The plantar reflexes are usually extensor in severehead injuries. With a coexisting acute spinal cordtransection, a slow flexor plantar response is oftenseen, and this can be a useful corroborative finding inan unconscious patient. Absence of sweating may thenclinch the diagnosis of cord damage: this is bestdetected by running the dorsal surface of the exami-ner’s fingers up the body – the change from dry tomoist skin is unmistakable.

The motor findings have considerable significance.The prognostic importance of the GCS motor responsehas been generally confirmed, though in youngchildren the finding of generalized extensor patterns isnot so adverse as in adults (Robertson and Pollard,1955). A lateralized limb weakness may mean acontralateral (rarely ipsilateral) intracranial clot, espe-cially if serial records have shown that movementswere previously symmetrical. Other important causesinclude cerebral infarction from internal carotid occlu-

sion. Bilateral flaccid leg weakness very stronglysuggests a spinal lesion; bilateral leg weakness issometimes seen after cranial injury in the vertexregion, but is likely to be spastic, and should not showabsence of sweating. A flaccid arm weakness means abrachial plexus paralysis until proven otherwise,though in the acute phase of cerebral injury, ahemiplegic arm sometimes shows reduced tone andeven depression of tendon reflexes (Russell, 1947).

Abnormalities of the motor examination can only bereliably inferred in the absence of neuromuscularparalyzing drugs or sedatives such as barbiturates andbenzodiazepines. Use of a nerve stimulator may behelpful, if paralytic drugs have been used. Nurses andresidents should avoid repeated painful stimuli formotor-system testing in patients who are pharmaco-logically paralyzed or heavily sedated for ICPcontrol.

8.2.8 CARDIORESPIRATORY PARAMETERS

Pulse rate, blood pressure and respiratory rate havelong been recognized as valuable indicators of raisedintracranial pressure (ICP). In 1901, Theodor Kocher ofBern clearly associated higher grades of raised ICP.with slowed pulse and slow, shallow breathing inter-rupted by deep breaths; thanks to the experimentalwork of his brilliant young American protege HarveyCushing he was also aware that when raised ICPcompromised the medullary vasomotor centers, theblood pressure would rise (Kocher, 1901).

These signs of brain-stem failure now have lessdiagnostic value in cases of severe head injury, beingseen chiefly as late events after failure of treatment.Nevertheless, the pulse, blood pressure and respira-tion should be monitored routinely and in less severehead injuries may give valuable advance warning ofraised ICP. In children especially, a slowing pulsesometimes appears before an obvious fall in theconsciousness level. Conversely, tachycardia and afalling blood pressure may be of great importance indetecting an extracranial lesion such as a rupturedspleen or other abdominal or thoracic organ.

The prognostic significance of the cardiocirculatoryparameters received surprisingly little attention inearlier studies of severe closed head injury (Teasdaleand Jennett, 1976; Jennett and Teasdale, 1977). How-ever, with increasing awareness of the critical impor-tance of cerebral perfusion pressure, the significance ofa low blood pressure has received more attention.Stening et al. (1986) found records of an arterial bloodpressure below 90 mmHg persisting for more than 60minutes in 90/290 (31.0%) cases of acute subduralhematoma, and analysis showed that this was a strongpredictor of bad outcome. These authors saw arterialhypotension as a preventable cause of bad outcome,


and this is indisputable when hypotension is due toinadequate resuscitation or failure to deal with anextracranial lesion. But arterial hypotension may alsobe seen as a manifestation of terminal brain-stemfailure, and then a bad outcome may be inevitable. Lyleet al. (1986), in a study of severe head injury, found thata systolic arterial blood pressure below 90 mmHg wassignificantly associated with death on univariantanalysis; however, in this study hypotension correlatedclosely with a low GCS score and on multivariantanalysis the only significant variables were the GCSscore and the pupillary light reflexes. Choi et al. (1988)also found that blood pressure on admission did notcorrelate significantly with outcome.

The converse finding of hypertension has receivedless attention, though Robertson et al. (1983) havegiven prominence to arterial hypertension as anadverse event in severe head injury. Fearnside et al.(1993) considered the prognostic significance of parox-ysmal arterial hypertension as a clinical variable in aseries of 315 severe head injuries; it was seen inassociation with profuse sweating and tachycardiaand did not adversely affect mortality.

Respiratory abnormalities were studied by Northand Jennett (1974) in a series of acute neurologicaldisorders. They found that bad outcomes were asso-ciated with abnormal breathing patterns, and inparticular with tachypnea combined with hyper-ventilation. With the advent of routine early intuba-tion and control of blood oxygen saturation by pulseoximetry, spontaneous respiratory patterns have losttheir diagnostic and prognostic significance; the initialABC examination always includes an assessment ofthe adequacy of breathing, but a detailed descriptionof the rhythm does not add much to the overallevaluation of injury severity.

8.2.9 EXTERNAL FINDINGS

In the unconscious acute head injury, concern with thestate of neurological function may overshadow therest of the clinical examination. It is easy to omit anexamination for external signs of injury. The scalp andface should be carefully inspected and palpated.Wounds, abrasions and swellings should be recordedon a diagram and also photographed if there aremedicolegal implications. If for any reason CT scan-ning is not possible, the site of the primary impact isan important guide to the siting of an emergencycraniotomy or burrhole exploration. The impact site(s)may also be important in future litigation, for examplein determining whether a helmet might have giveneffective protection, or in a victim of child abuse orother form of criminal assault.

Orbital swelling has obvious diagnostic importanceas a sign of anterior fossa fracture; auscultation may

detect a carotid–cavernous fistula. Bruising behind theear (Battle’s sign) is a well-known sign of a fracturedpetrous bone. However, if bruising is seen imme-diately after injury, it may point to a local impact. Ifthe bruising appears after a time interval, it is likely tobe due to a fracture of the skull base.

Blood or cerebrospinal fluid (CSF) leakage from thenose or ear should be noted and a sample of fluid(> 0.1 ml) should be sent for immunochemical analysisfor �2-transferrin as a marker of the presence of CSF(Ryall, Peacock and Simpson, 1992).

8.3 The definitive examination

8.3.1 TIMING

This depends on the speed and degree of recovery.Ideally, a full neurological examination is done whenthe patient is conscious, cooperative and fully ori-ented. Since recovery from a severe head injury isusually slow and often incomplete, more or lessselective serial neurological examinations are usuallydone at intervals before full cooperation is complete,and when the patient is still in the phase of post-traumatic amnesia (see below). These progress exam-inations can be very informative. It is very importantin planning and assessing rehabilitation, and also formedicolegal purposes, to ensure that all residualneurological disabilities are documented before thepatient goes home or is transferred to another hospi-tal. In particular, residual amnesia should be assessedand the senses of sight, smell and hearing should betested. Therefore, a definitive neurological examina-tion is mandatory before discharge or transfer.

8.3.2 ORGANIZATION

Who does the definitive examination? In many centers,the neurosurgeon is a surgical neurologist and exam-ines the patient in person or delegates to a properlytrained proxy. In some centers, a medical neurologistmay be consulted. Increasingly and beneficially, partsof the examination are now subcontracted to aneuropsychologist, neuro-ophthalmologist, neuro-otologist or specialist in neurorehabilitation; pediatricneurosurgeons may consult a specialist in devel-opmental neurology. Whatever the division of labor,there needs to be a final common synthesis andevaluation, preferably made by a single person withfinal clinical responsibility.

8.3.3 ORIENTATION AND AMNESIA

Orientation is always confirmed as part of thedefinitive examination. As a minimum, the patientshould be asked to name the day of the week, date and

THE DEFINITIVE EXAMINATION 157

place. The patient should also be asked to describe thelast event recalled before the injury and the first eventrecalled after the injury. These questions should defineand quantify the periods of retrograde amnesia (RA)and post-traumatic amnesia (PTA). In patients emerg-ing from a prolonged amnesic state, one of the amnesiaquestionnaires described below can be used.

8.3.4 SPEECH, MENTAL STATE AND COGNITION

Speech is assessed in conversation, both for impairedarticulation and for fluency and thought content.Minor degrees of dysarthria can be brought out bytongue-twisting words, such as ‘hopping hippopot-amus’. A tape recording of speech may be made forfuture comparison.

The preferred hand is recorded, though it must beremembered that many left-handed persons have fullor partial left-hemisphere dominance. If there is reasonto suspect injury to the dominant hemisphere, thepatient is asked to name a series of test objects ofincreasing complexity: for adults, the final challengecan be the parts of a watch and for children a toy. Thistest for nominal dysphasia can also be used to testrecent visual memory, by asking the patient to recall asmany as possible of the objects immediately after thenaming test; 8/10 is a good score. Other standard testsof memory include recall of a name, an address and aflower after 5 minutes, digit retention forwards andbackwards, and timed serial subtraction of 7 from 100.

Tests of cognition are best done by a neuropsycholo-gist; Walsh (1985) and Wood and Woodroffe (1995)have reported on tests found useful in head injurypractice. If the services of a neuropsychologist are notavailable, there are many simple tests that require littlespecial expertise; literacy can be checked with an age-graded word list and non-verbal intelligence can beassessed by the Raven colored matrix test (Raven,1986), which also probes function in the non-dominantparietal lobe.

The emotional state and the degree of insight arenoted in conversation and in discussions of futureplans for rehabilitation.

For head-injured children, cognitive capacities andmental attitudes can be assessed in play and gamesappropriate to the age; a child’s attempts to draw aman are very informative, and so are games based onfamily relationships. At some stage, a formal devel-opmental assessment (Griffiths, 1970) should be done;this requires considerable pediatric experience.

8.3.5 VISION

This is always assessed in severe head injuries, thoughthe depth and scope of the assessment vary with thenature of the injury. Covering one eye may bring out

subjective visual loss or blurring. The Snellen and/orreading test types should always be used in thedefinitive examination of a severe head injury. Forilliterates, the E tests can be used; alternatively, theSTYCAR toys provide a simple and quick way ofestimating visual acuity (Sheridan, 1976). Peripheralvisual fields are tested by confrontation with theexaminer’s fingers as stimulus. Central fields can betested with a small white or red object, such as thehead of a mapping pin, or a bead on a black stick. It isalso possible to assess the central fields very effec-tively by asking the patient to fix on the examiner’snose and to say if any feature is missing or blurred. Ifthere is a field defect, formal perimetry is done –usually by a neuro-ophthalmologist. The optic fundiare always examined; as noted above, a mydriaticshould not be used in the early period after a headinjury, but may be used later when definitive fundo-scopy is done.

8.3.6 SMELL AND TASTE

Olfaction must always be tested. Tar or phenol is agood strong test odor, but should be complemented bya milder odor such as banana or raspberry, or cloves.Each nostril is tested separately and, to excludeguessing, the patient is warned that the test bottle maybe empty. A more objective system of smell testing isprovided by the University of Pennsylvania Identifica-tion Test (Doty et al., 1984), a quantitative smell testthat permits the examiner to determine whether thereis normal olfaction, microsmia, anosmia ormalingering.

Taste is rarely of importance, but may be testedwhen there is a facial paralysis, by dropping strongsyrup or salt solution on each side of the tongue;electrical tests of taste are not always reliable, as thepatient may report tingling as a taste.

8.3.7 HEARING

This is tested with particular care when there isevidence of a skull-base fracture. A simple check isdone by whispering words or numbers into each ear,hearing by the opposite ear being masked by gentlecircular rubbing with a finger tip pressed on theopposite tragus to occlude the external auditorymeatus. If deafness is found, a 1024 or 512 Hz tuningfork is used to distinguish inner- and middle-eardeafness by the Weber and Rinne tests. The externalauditory canals are examined with an otoscope andthe color of the ear drum is noted. An otologist shouldbe consulted if hearing is impaired, or if there is ahemotympanum. An audiogram should also be per-formed, both to aid prognosis for recovery and formedicolegal reasons.


8.3.8 CRANIAL NERVES

The eye movements are tested in lateral, vertical andoblique planes, and note is made of ptosis, diplopia,squint or nystagmus.

The trigeminal nerve is tested in head injuriesassociated with facial or skull-base fractures. Thecorneal reflex is tested with a wisp of cotton wool.Mild trigeminal hypesthesia may be brought out bystroking parts of the face and asking the patient ifthere is any qualitative difference. Differences inpinprick perception may be checked, especially ifthere has been a facial injury; a blunted disposableneedle is used. Two-point testing on the lips issometimes useful.

The facial nerve is tested by asking the patient toscrew up the eyes, whistle or smile; an emotionalfacial weakness of upper motor neuron type may bebrought out by watching the spontaneous smile. Ifthere is any facial weakness, it is most important toknow whether it is of late onset. In unconsciouspatients, unless in deep coma, facial movements canbe elicited by strong pressure on the supraorbitalnerve or mandibular ramus. Schirmer’s test of lacri-mation is very useful in cases of peripheral facialparalysis: thin strips of filter paper are placed in theconjunctival sac for 30 seconds or more, and the extentof saturation is measured (Trott and Cooter, 1995).

The lower cranial nerves (nerves IX–XII) are testedby examining the movements of the palate, pharynx,tongue, trapezius and sternomastoid muscles.Peripheral paralyses of these nerves are occasionallyseen after closed head injuries. Much commoner aredysphagias and dysarthrias from brain-stem damage.For these an assessment by a speech pathologist isnecessary and a radiological swallow study isadvisable.

8.3.9 SENSORIMOTOR LIMB FUNCTIONS

Limb function is tested with respect to muscle tone,power against graded resistance, and coordination;ataxia is a very common sequel in severe closed headinjuries, presumably from injuries of the superiorcerebellar peduncle. Quantitative measures of limbfunction are desirable if cooperation is good. In mostunits, these are done by physiotherapists and/oroccupational therapists, but their value and limita-tions should be understood by all clinicians concernedin head injury evaluation. Dynamometry should beused to give an objective measure of hand grip(Mathiowetz, 1990); hand-held dynamometers can beused to test other muscle groups. Manual facility andcoordination can be quantified by finger tapping or bypegboard tests, and for these consultation with anoccupational therapist is advisable. Wood and Ham-merton (1995) have reported on the Purdue pegboard

test in evaluating head injury, both in adults and inchildren over the age of 7 years. This test was devisedfor selecting industrial workers (Tiffin, 1968); Gardnerand Broman (1982) found it to be an excellent test ofminimal brain damage. In the simplest form of thetest, the subject inserts metal pegs in a row of holes ina standard board as rapidly as possible. A score isobtained for each hand over a period of 30 seconds.The reproducibility of pegboard testing is impressive,and the test is of value as a guide in determining whena stable level of recovery has been attained. Otherquantitative tests of hand–arm function are describedby Gloss and Wardle (1982). If the patient can walk,the gait is described, and the ability to hop on eitherleg is noted; this is a good quick test of lower-limbmotor competence, though limb or spinal injury mayfalsify the interpretation. In patients unable to walk,the degree of mobility in bed or in a wheelchair isrecorded. The progress of motor recovery can bedocumented by video.

The tendon and plantar reflexes are again tested,and with more attention: persisting reflex abnor-malities have much more significance than the evanes-cent reflex changes seen in the acute phase.

Sensation, except in the trigeminal area, is rarelyaffected in closed head injuries, but occasionally onesees what appears to be a spinothalamic sensory lossin cases of brain-stem damage. A full sensory exam-ination is needed if there is an associated spinal injuryor suspicion of a lesion in the parietal lobe or basalganglia.

8.4 Evaluation of injury severity

8.4.1 PROSPECTIVE GRADING

Estimates of head-injury severity may be made pro-spectively, as aids in triage, prognosis and familycounseling. For these purposes, the estimate can takeinto account many factors and nuances; most clini-cians will admit that intuition enters assessments donefor prognosis. But when the estimate is done forstatistical purposes, as in therapeutic trials, the criteriashould be as few as possible, and they should be basedon observations that have good inter-rater reliability.

The consciousness level, assessed at a specifiedperiod after injury, has been widely used in definitionsof a severe head injury, both for prognosis and forresearch purposes. In most reports, the chief criterionof severity is a GCS score of 8 or less. For the USNational Coma Data Bank the definition for inclu-sion as a severe head injury is:

� GCS score of 8 or less following resuscitation,which may include endotracheal intubation; or

� GCS score deteriorating to 8 or less within 48 hoursof injury (Marshall et al., 1983b).

EVALUATION OF INJURY SEVERITY 159

In this definition the use of endotracheal intubationcould reduce the best verbal score to 1. In theory thismight result in the inclusion of less deeply uncon-scious patients, and it is reasonable to use the bestmotor score to control the reliability of the GCSsummated score. If this is done, the six-level Glasgowmotor scale should be used. Data from the six-levelmotor scale should be routinely recorded for audit andresearch studies.

This definition of head-injury severity is widelyaccepted, and is being used as a basis for inclusion intherapeutic trials. Thus, in a well designed phase 2trial of an oxygen radical scavenger, Muizelaar et al.(1993) accepted for entry into the trial cases with aGCS score of 8 or less who were unable to followcommands after resuscitation; the time at which theGCS score was estimated was not specified. Thecriteria for exclusion included ‘the likelihood of braindeath after resuscitation’; presumably this exclusionwould remove cases with GCS score of 3 and otheradverse signs.

The GCS has also been used to stratify cases withina more broadly inclusive trial. In a randomized trial ofnimodipine therapy for head injury, Bailey et al. (1991)accepted all patients who were unable to obeycommands, thus including GCS scores as high as 13.For statistical analysis, the best motor response wasused, the scale being collapsed into three classes – nilor extending; flexing; localizing. (These classes werefurther subdivided by the presence or absence of anintracranial lesion requiring operation.) This trialprotocol shows the flexibility of the GCS in stratifyinginjury severity and it seems likely that, in further trialsof neuroprotective agents, components of the GCS willbe used in various ways, depending on the level ofseverity at which the agent is expected to be beneficialand the size of the series to be analyzed.

8.4.2 RETROSPECTIVE GRADING: COMA DURATION

Head injury severity may also be assessed retro-spectively, for epidemiological and other researchstudies, especially in correlation with measures ofoutcome (see below). The duration of impaired con-sciousness has been much used as a retrospectivemeasure of injury severity. In contemporary neu-rosurgical practice, this is commonly done in twodifferent ways.

The duration of coma can be measured on the basisof serial clinical observations of responsiveness. Thus,Bricolo, Turazzi and Feriotti (1980), in a very thought-ful study, reported on 135 cases who were in coma 14days after head injury, coma being defined as ‘unre-sponsive . . . or incapable of obeying simple com-mands or showing any rapport with their environ-ment’. Outcomes were assessed at 1, 3, 6 and 12

months by the Glasgow Outcome Scale (Jennett andBond, 1975): by the categorization given in that scale,13.3% made good recoveries, 17.7% were left withmoderate disabilities, 31.1% were left with severedisability, 8.1% remained in persistent vegetativestates (Jennett and Plum, 1972) and 29.6% were dead.This study illustrates both the usefulness and thecomplexity of the duration of coma as a measure ofunconsciousness. Recovery from coma was identifiedin terms of the three components of the GCS.Spontaneous or evoked eye opening appeared after 1month in 76.3%. Response to commands came later,and was achieved after 3 months in only 52%. Speechrestoration was achieved by 3 months in only a thirdof cases, rising to 51% by the end of the study. Therewas a correlation between duration of coma andquality of final outcome. In this study, each measure ofresponsiveness was separately correlated with qualityof recovery. In theory, it should always be possible todo this if accurate GCS records are kept, but manyreports on the prognosis of traumatic coma have madethe simpler distinction between comatose and notcomatose on the basis of the summated GCS score.Lyle et al. (1986), who did this, noted that the GCSscore is a relatively insensitive measure of recovery,since the early return of spontaneous eye opening haslittle prognostic value. The GCS descriptors can becombined with terms such as akinetic mutism, apallicstate, and persistent vegetative state, but the sig-nificance of these terms is not always clear and theycan be dangerous labels if given a prognostic impor-tance during the first few months after injury.

8.4.3 RETROSPECTIVE GRADING: AMNESIA

The other widely used measure of duration ofimpaired consciousness is the period of PTA. RitchieRussell, in his pioneering study of the neurology ofhead injury (Russell, 1932), argued that the duration ofunconsciousness is best estimated as the period beforereturn of memory. He found that the return ofmemory could be timed by the patient’s recollection ofwhen he woke up. Russell believed that this wake-uptime could be estimated with fair accuracy long afterthe accident. On this basis, he graded surviving casesinto three groups – those unconscious for less than 1hour, those unconscious for 1–24 hours and thoseunconscious for longer periods. With later experience,Russell became aware that the first clear recollectioncould be followed by a further period of amnesia, andthe PTA was therefore measured by the return ofcontinuous memory (Russell and Nathan, 1946). ThePTA was correlated with return to full wartime dutiesafter head injury and appeared to be a robustprognosticator. Russell and his colleagues also studiedthe period of amnesia before the injury, retrograde


amnesia (RA); this was found to have less significanceas a measure of injury severity. The RA is stillgenerally recorded, as it has some diagnostic value;RA is often important in medicolegal issues, both asconfirmation of a cerebral insult and because itobviously affects the victim’s capacity as an accidentwitness. But the duration of RA often shrinks with thepassage of time; Richardson (1990), reviewing theabundant literature, concluded that the RA has nopractical value as an indicator of injury severity or inprognosis.

There has been general agreement that the PTA is avery valuable measure, especially for less severeinjuries, but there has been doubt as to the reliabilityof amnesia endpoints ascertained by simple retro-spective questioning. In the first place, the period ofPTA may be interrupted by islands of recollection;Gronwall and Wrightson (1980) found such islands in26 (39%) of 67 minor head injuries. Awareness of thisphenomenon led to the definition of the PTA as theperiod of continuous memory loss after injury (seeabove), but this also has proved to be hard to define byretrospective interrogation. Much of Russell’s veryproductive work was done on British soldiers trans-ferred to Oxford for assessment and rehabilitation. Intheir passages from accident site or battlefield toevaluation, they had usually experienced a series ofwell-defined and well-documented events that maderetrospective estimation of return of continuous mem-ory easier than in cases where all treatment has beenundertaken in a single institution. Furthermore, inRussell’s earlier reports the proportion of cases withvery prolonged periods of amnesia was not high(Russell and Nathan, 1946; Russell, 1954). In laterstudies on a larger database, Russell accepted thatfactors other than the severity of injury influenced thePTA, notably the presence of focal brain lesions, severeassociated extracranial injuries, and the age of theinjured person (Russell and Smith, 1961; Richardson,1990). Present-day practice is especially concernedwith cases slowly emerging from prolonged coma orconfusional states, and retrospective interrogation isoften done after the patient has been (quite rightly)briefed by family members on the course of events: thepatient may then confuse what is remembered withwhat has been told, giving a falsely short PTA. This isespecially likely to happen in children, and retro-spective PTA measurements in children under the ageof 8–10 years are very unreliable. On the other hand, aretrospective PTA evaluation done weeks or monthslater may give a falsely long measure, since the patientmay have forgotten some landmark event or may havebecome confused between true recollections andsecond-hand information. For these and other reasons,efforts have been made to determine the PTA by morereliable means.

Richardson (1990) and Forrester and Geffen (1996)have reviewed the development of prospective meas-urements of the PTA – prospective in the sense that theaim is to detect by ongoing assessments the time atwhich the return of continuous memory can bedemonstrated objectively. These tests embody stan-dardized questionnaires, which are presented to thepatient at regular (usually daily) intervals until theanswers are considered to indicate that the patient hasemerged from PTA. The best known is the GalvestonOrientation and Amnesia Test (GOAT) designed byLevin, O’Donnell and Grossman (1979). This testsorientation in considerable detail (Table 8.7), allottingerror points for disorientation. The test also gives errorpoints for PTA and RA; for each, five error points arededucted for inability to recall a verifiable, or at leastplausible event before or after injury, and an addi-tional five error points when the patient cannot givedetails of this event. A final score is made bysubtracting the sum of the error points from 100; ascore of 75 or more is said to be within normal limits.The GOAT is open to the obvious objection that thisnormal score is in theory obtainable when a patient is

Table 8.7 Galveston Orientation and Amnesia test(Source: after Levin, O’Donnell and Grossman, 1982)

QuestionsMaximum no.

error points

What is your name? 2Where do you live? 4Where were you born? 4Where are you now?

City 5Hospital (need not be correctly named) 5

On what date were you admitted to thishospital?

5

How did you get here? 5What is the first event you remember after

the injury?5

Describe event in detail, e.g. date, time,companions

5

What is the last event you remember beforethe injury?

5

Describe event in detail, e.g. date, time,companions

5

What time is it now? (1 error point per halfhour removed from correct time)

5

What day of week is it now? (1 error pointper day removed from correct day)

3

What day of month is it now? (1 error pointper day removed from correct day tomaximum of 5)

5

What is the month? (5 error points permonth removed from correct month tomaximum of 15)

15

What is the year? (10 error points per yearremoved from correct year to maximum of30)

30


fully oriented but still in an amnesic state; Gronwalland Wrightson (1980) found that a head-injuredperson may be oriented but amnesic, or vice versa.Nevertheless, Levin, O’Donnell and Grossman (1979)found that GOAT scores correlated well with theduration of GCS impairment and with the finaloutcome.

Ewing-Cobbs et al. (1990) have devised a pediatricversion of the GOAT, the Children’s Orientation andAmnesia Test (COAT). This does not attempt to testthe PTA in any way, but does include a quantitativeevaluation of temporal orientation, using the classictest of forward digit retention and the more modishcapacity to recall television programs. The COAT isapplicable in full to children in the age range 8–15,and without the memory tests in children as young as3 years. Baryza and Haley (1994) have used the COATas a screening test for otherwise undetected impair-ments in memory and orientation in children whoappear to have recovered from head injury, and thismay be its most valuable application.

Two leading Australian neurorehabilitation unitshave designed simple questionnaires for evaluation ofthe PTA. From Sydney, Shores et al. (1986) havereported on the Westmead PTA scale. This embodiestwo biographical questions, five questions related totime date and place and three questions assessingrecollection of pictures of objects (Table 8.8). Theability to remember the examiner’s face and name arealso tested. The patient is deemed to be out of the PTAwhen able to give correct answers in all components ofthe scale on three consecutive days. Shores (1989)compared this scale with the duration of comameasured with the GCS and concluded that theWestmead scale was a better predictor of outcome.Haslam et al. (1994) have further explored the relationbetween long-term cognitive impairments and PTAestablished with the Westmead scale. These authorshave reported on a new variable, the post-comadisturbance (PCD). This is the period of confusionafter emergence from coma and is derived by subtract-ing the duration of coma from the duration of PTA. Inthis study, it appeared that the PCD was a significantpredictor of impairment in recent memory 12 monthsafter injury, whereas the PTA better predicted poorperformance in information processing. With both thePCD and the PTA, the relations between duration andcognitive impairment were non-linear.

Forrester and Geffen (1996) have criticized theWestmead scale on practical grounds, and advocatethe scale used in the Julia Farr Centre, Adelaide. In thisscale (Table 8.9), the questionnaire has six orientationitems and five memory items. In the memory items,the patient is asked to memorize the name attached toa photograph, a gesture, and the names of threeobjects shown in photographs. Memory is not tested

until full orientation is confirmed. In this test also,PTA is deemed to be ended when the patient scorescorrectly in all orientation and memory tests on threeconsecutive days.

G. Geffen (personal communication) finds that theGOAT and Julia Farr Centre PTA scale correlateclosely, and the choice of scale may be a matter of unitpreference rather than theoretical advantage.

8.4.4 APPLICATIONS OF CLINICAL EVALUATION

It seems that for most clinical trials, severe headinjuries are best defined prospectively by the GCSscore, either summated or as the best motor score,

Table 8.8 Westmead PTA Scale questionnaire – this ispresented daily until the patient achieves a perfect score of12 on three successive days; the PTA is deemed to haveended on the first of the three days (after Shores et al., 1986)

QuestionsMaximumNo. points

1. How old are you? 1

2. What is your date of birth? 1

3. What month are we in? 1

4. What time of day is it? 1

5. What day of the week is it? 1

6. What year are we in? 1

7. What is the name of this place? If thepatient does not know, a multiplechoice is given – home, name ofhospital, name of another hospital

1

8. The patient is asked to remember theexaminer’s face. On the following day,he/she is shown three photographs, oneof the examiner, and asked to identifythe examiner

1

9. The patient is asked to remember theexaminer’s first name. On the followingday, he/she is asked to recall thisname; if unable to do so, he/she isasked to select the name from a seriesincluding this name and twophonologically similar names or nameswith an equal number of syllables

1

10. Pictures I, II and III: the patient isshown three colored pictures ofcommon objects and asked to namethem. On the following day, the patientis asked to name the pictures. If unableto do so, he/she is asked to identifythese pictures in a series of 12 pictures,being a random assortment of the threeoriginal pictures and nine distractorpictures

3

Total 12


Table 8.9 Julia Farr Centre Post-traumatic Amnesia Scale®. Orientation tests: These include four autobiographicalquestions, one question on time of day (cf. Question 4 in Westmead Scale) and one on place (cf. Question 7 in WestmeadScale). Orientation is tested daily until a score of 6 or more is achieved on three successive days. Memory tests: Whenoriented in person, time and place, the patients is taught to memorize a gesture, the name of a person seen in ablack-and-white photograph and three objects seen in black-and-white photographs – a cup, a comb and an umbrella.On the following and successive days, the patient is asked to recall these, first freely and if unable to do so, after cuedprompting by showing the test gesture or photograph together with a distractor. When the patient is oriented andachieves a minimum memory score of 5 (gesture ≥ 1, name ≥ 1, picture ≥ 1) on three successive days, the PTA endpointis recorded for the first of the three days. (Source: from Forrester and Geffen, 1996)

Orientation tests

Questions Answers Score

a. Personal orientation:

1. What is your name? No answer or wrong answer 0Correct answer 1

2. Are you married/Do you live with a partner? No answer or wrong answer 0Correct answer 1

3. Do you have any children? No answer or wrong answer 0Correct answer 1

4. What is your job? No answer or wrong answer 0Correct answer 1

b. Orientation in time:

5. What time of day is it?(Is it morning, afternoon or night?) No answer or wrong answer 0

Prompted correct answer 1Unprompted correct answer 2

c. Orientation in place:

6. Where are we now?(Are we at home, in a hospital or a hotel?) No answer or wrong answer 0

Prompted correct answer 1Unprompted correct answer 2

Orientation daily total Maximum score 8

Memory tests

Test ResponseMaximum

score

1. Gesture Free recall 3Cued recall 2Recognition 1

2. Name of person in photograph Free recall 3Cued recall 2Recognition 1

3. Pictures – (i) Free recall 3Recall after cue 2Recall when shown and reject the distractor 1

– (ii) Free recall 3Recall after cue 2Recall when shown and reject the distractor 1

– (iii) Free recall 3Recall after cue 2Recall when shown and reject the distractor 1

Picture total (i) + (ii) + (iii) 9

Memory total 15


determined after resuscitation. For prognostic pur-poses, the GCS score can be strengthened by takinginto account other predictors, notably age, arterialblood pressure and the absence of pupillary lightreflexes on one or both sides. Choi et al. (1988) havetried to refine the prognosis after severe head injuryby preparing three graphs relating outcome to motorscore, pupils, and age.

The prognostic importance of increasing age isnow well documented. Jennett and Teasdale (1981)studied outcomes in severely head-injured personswho remained in coma for at least six hours. Therewas a linear relationship between age and badoutcome (death or vegetative survival) and over 70years there were no good recoveries. Luerssen,Klauber and Marshall (1988) also found an increasein mortality rates with advancing age; for comatose(GCS < 8) patients, the death rate rose steeply in the45–49-year age group, and remained between 60%and 80% thereafter. Conversely, comatose childrenover the age of 5 years tend to have better outcomes.Infants and young children do not show this favor-able tendency, but the difficulties in grading comabelow the age of 5 years make it necessary to becautious in using the consciousness level for prog-noses in this age group (Simpson et al., 1991), andespecially in extrapolating adult experience to theprognosis in injured infants.

For retrospective classification of head-injury sever-ity, it is still debatable whether duration of coma orlength of PTA is the better yardstick. Much effort hasgone into this debate, and some of this representsquests for precision in a field where in reality precisionis impossible. For patients who emerge from coma tobecome responsive and cooperative, the time ofrecovery from confusion and amnesia has pragmaticimportance in rehabilitation and prognosis and asimple standardized endpoint test is desirable; toestablish this, a questionnaire is certainly useful.Wilson et al. (1993) have emphasized that the PTA is ofvalue as a measure of injury severity, even whenascertained by the traditional method of retrospectivequestioning; when compared with coma duration, thePTA correlated better with lesion severity measured inMRI scans. Nevertheless, duration of coma is alsoimportant. There appears to be agreement that comapersisting after 14 days is a very adverse finding andusually predicts a severe disability. Clinical recordsshould be maintained to ensure that this period iswell documented for future reference. It is alsodesirable to record separately the return of eyeopening, responsiveness to commands and capacity tocommunicate.

This book is concerned only with severe headinjuries, but it should be noted that Rimel et al. (1981,1982) have used the GCS within 1 hour of admission

to identify minor (GCS score 13–15) and moderate(GCS score 9–12) head injuries. This has an attractivesimplicity, but Johnstone et al. (1993) found poor inter-rater consistency in defining a moderate head injuryon the basis of a coma scale, especially when used bya relatively inexperienced observer. For less severehead injuries, PTA estimated at discharge seems to bea preferable criterion. When an exact definition of arelatively short period of PTA is needed for researchpurposes, it may be advisable to administer a simpleorientation questionnaire at short intervals, takingaccurate answers to a standard set of questions as theendpoint (Gronwall and Wrightson, 1980).

8.4.5 CLINICAL EXAMINATION AND OUTCOME

Outcome grading is discussed in Chapter 22. Theassessment of outcome requires a synthesis of medicaland social data, and the whole spectrum of post-traumatic neurological disability, unique in each indi-vidual, has to be taken into account. An appropriateclinical assessment is therefore an essential part ofoutcome evaluation. The purpose of the assessmentdetermines its depth and scope.

Epidemiological outcome studies require broadcategorizations based on social functional evaluations;these categorizations are discussed in Chapter 22.

Rehabilitation requires an atomistic analysis offunction, repeated over time. A comprehensive neuro-logical examination is an essential prelude to anyrehabilitation program. A preliminary and selectiveneuropsychological evaluation is also desirable, andwhen a planned program has been concluded, a fullreassessment is essential. It is often desirable to repeatsuch assessments at scheduled times. Victims of headinjury often express resentment that rehabilitation hasbeen discontinued too soon, and this may in part stemfrom failure to promise a future review of progressand perhaps a further cycle of rehabilitation.

In the USA, Australia and many other countries, thelegal system requires definitive or interim medicalassessments of disability. These have to be bothatomistic and holistic. In assessing the outcome of asevere head injury for medicolegal purposes, theimpact of the cerebral injury must be evaluated interms of physical, cognitive and behavioral effects,but also in its effects on the victim’s social status andquality of life.

Table 8.10 sets out the chief complaints voiced afterhead injuries; each requires detailed analysis andobjective verification where possible. It should benoted that the causes of some of these complaintsinclude non-neurological injuries of the facial skeleton,the facial viscera or even extracranial structures.

Efforts are being made to formulate the effects ofinjury in percentages of total impairment (American


Medical Association, 1993). These formulations aredifficult to apply in a realistic way when the cognitiveand behavioral outcomes of head injury are underconsideration, but can be meaningful if given as broadassessments of social incapacity.

The purpose of outcome evaluation also determinesthe timing of the final examination. For researchpurposes, a relatively early evaluation may be accept-able. Choi et al. (1994) have argued for an assessmentof outcome at 6 months after injury. For medicolegalevaluations, a later period is necessary, both becausemuch functional improvement may become evidentafter 6 and even 12 months, and also because all

parties should be satisfied that a plateau in recoveryhas been reached. As a rule, 2 years or more shouldelapse. In children, the final examination is usuallydeferred until adolescence, so that the impact of thehead injury on the child’s educational experience canbe assessed and quantified by neuropsychologicaltests. Such a prolonged deferral may have adversefinancial consequences for the child’s parents, andthere should be legal provision for interim evaluationat an earlier date, if the child’s upbringing is in anyway dependent on a monetary settlement.

Table 8.10 Medicolegal checklist – the first column liststhe chief complaints made after severe head injury (the listis not exhaustive), the second sets out the chiefimpairments or other conditions usually associated witheach complaint

Complaint Common causes

Personality change Cerebral damage, especiallyfrontal lobe damageLoss in lifestyle, depression

Poor memory, poorconcentration, reducedintelligence

Cerebral damageDepression

Speech defect Cerebral damageCerebellar damageCranial nerve injury

Blackouts, giddinessand ‘funny turns’

EpilepsyVasovagal attacksPostural vertigo

Headache, facial pain,scalp pain

Tension statesNerve injuryMigraine (rare)

Loss of smell/taste Olfactory nerve injury

Deafness, noise in ears Injury to ear and/or auditorynerveCranial bruit

Visual loss Injury to eye and/or visualpathways

Double vision Injury to cranial nerves III, IV, VIEye injury (rare)

Impaired swallowingand/or chewing

Injury of lower cranial nervesMaxillofacial injuryInjury to dentition

Limb weakness,tremor, unsteadiness,gait change

Cerebral injury affecting motoror sensorimotor pathwaysCerebellar injurySpinal or limb injury

Incontinence and/orimpotence

Spinal injury; cerebral injury –especially frontal lobe injury

Disfigurement Scar, loss of hair, cranial or facialdeformity, eye injury

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