Normal computerized tomography scans in severe head injury

Abstract

The authors analyze the clinical course of 46 severely head-injured patients who had completely normal computerized tomography (CT) scans through the immediate posttraumatic period (1 to 7 days after trauma). These patients represent 10.2% of a consecutive series of 448 cases of severe head injuries and two-thirds of the cases showing a normal CT scan on admission (the other one-third of the cases developed new pathology). The usual course in these 46 patients after the initial coma was toward progressive neurological improvement, and 35 patients (76%) achieved a functional level of survival. Nine patients (19.5%) remained comatose for several weeks and developed severe disability. There were two fatalities due to medical complications. The final outcome was more closely related to the duration of coma (the longer the duration the worse the result) than to the initial Glasgow Coma Scale (GCS) score. In fact, 26% of the patients in the lower GCS score ranges (3 to 4 points) made a good recovery and 46% developed moderate disability only. These findings indicate that the grim prognostic significance of deep posttraumatic coma is tempered in the presence of a normal scan. However, the absence of CT abnormalities in severely head-injured patients cannot be equated with a good prognosis because in one-fifth of the cases serious permanent disability develops. Sustained elevation of the intracranial pressure (ICP) was not seen in these patients, indicating that ICP monitoring may be omitted in cases with a normal scan. However, since one-third of the patients with a normal admission scan developed new pathology within the first few days of injury, a strategy for control scanning is recommended. Control CT scans performed more than 6 months after injury showed a significantly higher incidence of brain atrophy in patients developing permanent disability than in those who made a good recovery.

Neuropsychological correlates of forgiveness

“…can be used to identify the structural integrity of the brain, neuropsychological tests can be used to infer functional integrity of different cerebral structures (Lezak, Howieson, & Loring, 2004). Neuropsychological tests have been shown to be a valuable complement to neuroradiological measures, given that they have been shown to identify brain dysfunction earlier than neuroradiological techniques in persons with Alzheimer's (Gomar, Bobes-Bascaran, Conejero-Goldberg, Davies, & Goldberg, 2011), as well as impaired cerebral areas despite intact structural imaging in persons with severe brain injury (Lobato et al, 1986). However, it is noted that neuropsychological tests can only be used to infer general areas of dysfunction, compared to structural indices, which are more specific.…”

Let live or let die after traumatic coma

“…Indeed, in a series of 448 consecutive severely head-injured patients, only 10% had normal cerebral CT scans during the immediate posttraumatic period (1 to 7 days after trauma). 18 Hence, instead of excluding 90% of traumatic comatose patients, we propose to offer patients with absent SEPs systematic examinations with appropriate brain MRI sequences that explore the anatomy of the traumatic lesions, coupled with a careful examination and a proper interpretation of the images.…”

Prognostic Factors in Children with Severe Diffuse Brain Injuries: A Study of 74 Patients

“…Ong et al [41]in 151 children admitted within 24 h of injury, noted that the GCS alone 24 h post injury had a limited predictive value, but when associated with hypoxia and CT scan features of DAI or DBS or subarachnoid haemorrhage the prognostic value of the GCS was enhanced two- to four-fold, and correct predictions based on these were possible in 90.1% of patients. Lobato et al [42]in 46 severely head injured patients who had normal CT scans, found that the final outcome was more closely related to the duration of coma than to the initial GCS. Amongst the GCS, motor score has been found by various authors to significantly correlate with the outcome.…”