¹Senior Resident, ²Professor And Head Department of General Surgery, Government Medical College and Hospital, Miraj District-Sangli, Maharashtra, INDIA.

Email: kumarplash@gmail.com

RESULTS

Out of the 120 patients majority were from the age group of 18-40 years (66%). Others were 41- 50 years (20%), 51- 60 years (12 %) and 61- 70 years (2 %). the Mean age was 36.6 years old. Majority of patients who had come were of male gender (90%), Male to Female ratio was 9:1.

TABLE 1: Age and gender in relation to head injury

47(39%) patients were classified as SEVERE head injury according to GCS scoring system i.e. GCS score of 8 or less (44 died and only 3 survived that too with severe disability). The remaining 73(61%) patients were of Moderate brain injury i.e. GCS score between 9- 12 (46 had good recovery and 23 had moderate disability).

Table 2: Severity of head injury based on Glasgow coma scale.

The patients with Favourable outcome i.e. Good recovery and Moderate Disablement were 69(57%), and patients with Unfavourable outcome i.e. severely disabled and who died during treatment were 51(43%).

Table 3: Percentage of outcome based on Glasgow outcome scale.

It was observed that those patients whose Glasgow coma score on admission was 8 or less (severe head injury) required intubation and hence were intubated. All patients of severe head injury criteria were intubated in our study. Patients with GCS score between 9- 12 did not require intubation as they maintained SpO2 levels above 90% on admission.

Table 4: Patients intubated.

In our study EDH and SDH were the most common findings on non-contrast brain CT scan. EDH comprising of 27% and SDH comprising of 26% making the majority 53% of the population. SAH was the third highest finding making up 18% of the population, followed by haemorrhagic contusion (11%) and intra-parenchymal haemorrhage (7%). In 11% of the head injured population CT scan could not be done as they were not in a stable condition. We found out that mortality was least with EDH, none of the patients who was diagnosed with EDH on CT scan imaging died in our study, whereas SDH had the highest mortality as 13 patients out of 44 died due to SDH, SAH and Intra-parenchymal haemorrhage comprised of 7 each mortality and Haemorrhagic contusion resulted only in 3 mortality out of 44. All patients whose CT was not done died eventually as they had severe head injuries.

Table 5:  Intracranial findings on CT scan.

99 patients (82%) were managed conservatively with monitoring in the surgical intensive care unit without the requirement of operative intervention. Operative interventions were required only in 21(18%) patients which included Craniotomy (7 patients) and Burr Hole (14 patients).

Table 6: Mode of management

The patients with Favourable outcome i.e. Good recovery and Moderate Disablement were 69, and patients with Unfavourable outcome i.e. severely disabled and who died during treatment were 51. Out of the 108 Male population 63 (58%) had good recovery/moderate disability and 45 (42%) had severe disability/died. Whereas the female population had 6 (50%) favourable outcome and 6 (50%) unfavourable outcome.

Table 7: Gender in relation to outcome.

DISCUSSION

Since the 1970s, when Teasdale and Jennett⁷ established the Glasgow Coma Scale, the scale has been the subject for numerous papers. The identification of variables in the acute stage of head injury that could provide insight into patient outcomes is of great interest to healthcare providers and researchers. The GCS score is one such variable. Numerous researchers have investigated the use of the GCS score in predicting outcomes in head injury patients. In a study by Haroon S. et al., 79.2% cases belonged to the first four decades of life, the maximum number of patients were in the age group of 21 to 30 years (25.3%).⁸ Similar observations have also been made by Tandon et al.⁹ who reported the mean age of 25.87 years in a series of 681 patients, whereas the mean age of the patients studied by Turazzi; et al.,¹⁰ was 34 years. The Mean age in our study was 36.6 years, which was similar to the findings of other studies mentioned here. The Male to female ratio was 9:1. Different Indian authors noted similar findings, such as Sambasivan M ¹¹ (15:1), Bharti P ¹² (5.6:1) and Haroon S et al.,¹⁰ (3.5:1). Out of the 120 patients participating in our study, 47(39%) patients were classified as severe head injury on admission according to the GCS score i.e. with GCS 8 and less, out of 47 patients who were classified as severe head injury 44 died and only 3 survived that too with severe disability. All patients who had an initial GCS score in the range of severe head injury (3-8) had an unfavourable Glasgow outcome score i.e. they were either severely disabled or died during treatment. Mittal B et al. observed 47.5% mortality in patients with the score of 3-7 and 10.7% deaths in those having the score ranging from 8 to 13 while only 7% cases with the score of 14-15 died.¹³ Mishra HB et al. found mortality figures of 62% in those having score of 3-7 while 12.8% and 2.2% died who had Glasgow Coma Score of 8-14 and 15 respectively.^14. Present study confirms the prognostic value of Glasgow Coma Score. A number of the studies included in this review used descriptive analyses in reporting the relationship between specific GCS scores and certain outcome categories.^15-18 Most studies reported positive outcomes in patients who presented with high initial GCS scores. Young et al.,¹⁵ found that 72 of the 76 patients with initial GCS scores of 8-15 had a good recovery or moderate disability, as measured by the GOS. Similarly, 99% of patients with GCS scores of 13- 15 had good recovery (Pal et al.,¹⁶), while 89%-96% of patients with a GCS score of 8 or above (Bishara et al.,¹⁷) and 75% of patients with GCS score 6 and above (Changaris et al.,¹⁸) also had good recovery or moderate disability outcomes. It was observed in our study that patients who had a GCS of 3, did not survive, showing similar findings as Demetriades study.^19. Bansal S et al.,²⁰ noted that the highest accuracy rate was seen for Glasgow Coma Scale (i.e. 84.3%). GCS had a good predictive power and had good discriminative ability between survivors and non-survivors, GCS had the added advantage of being simple and practical.⁹⁰ Choi et al.,²¹ and Narayan et al.,²² created the outcome categories of good or favourable outcome and poor or unfavourable outcome. The category of good outcome was composed of patients who had good recovery or moderate disability, while the poor outcome category included patients who had severe disability, persistent vegetative state, or death. By creating these broad outcome categories, the researchers were able to demonstrate better accuracy in their outcome predictions. Choi et al.,²¹ and Narayan et al.,²² reported accurate outcome predictions as high as 80% when using early GCS scores and these outcome categories. Poon, Zhu, Ng, and Wong^23.reported a 71% accuracy prediction rate of the GCS using similar outcome categories of moderate/severe disability and good recovery. Thus, the use of broad outcome categories increased the ability of the GCS score to predict patient outcomes. A relationship between assessments of the GCS and the outcome was shown clearly by Gennarelli et al.,²⁴ who demonstrated the existence of a continuous, progressive association between increasing mortality after a head injury and decreases in GCS score from 15 to 3. The NICE Guideline CG176 (2014, updated 2019) Head injury ^6.: assessment and early management states that “Intubate and ventilate all patients with GCS 8 or less requiring transfer to a neuroscience unit, and any patients with the indication detailed below-Intubate and ventilate the patient immediately in the following circumstances:

1. Coma-not obeying commands, not speaking, not eye opening (i.e. GCS 8 or less).
2. Loss of protective laryngeal reflexes.
3. Ventilatory insufficiency as judged by blood gases: hypoxemia (PaO2 <13 k Pa on oxygen) or Hypercarbia (PaCo2 >6 k Pa).
4. Spontaneous hyperventilation causing PaCO2 < 4 k Pa.
5. Irregular respirations.

Knowledge about the potential outcomes for head-injured patients based on these early GCS scores can prove to be invaluable to the families, and to healthcare professionals who care for and support these patients and their loved ones throughout the recovery process. By having information about the potential outcomes in head-injured patients, health care providers may facilitate earlier consultation of these services, which could improve outcomes for the head-injured patient. Many factors in head injury patients have been assessed and analysed, however, now is the time to expand our use of clinical knowledge beyond the Glasgow Coma scale, and create new scoring systems that take other variables like pupillary reactivity into account for establishing prognosis of head injury patients. Regardless of how many people perceive the Glasgow coma scale and it’s assessment of prognosis through the Glasgow outcome scale, it has proven to be widely used, easy form of examination that can help in predicting patient’s future with or without disability. As long as its purpose and its benefits are appreciated, it can have an essential role in predicting outcome of patients with head injury in the future for many more years to come.

CONCLUSION

Initial Glasgow coma scale score is a very efficient predictor of prognosis in head injury patients and it has a very good corroboration with Glasgow outcome scale. Patients who had an initial GCS score in the range of severe head injury (3-8) had an unfavourable Glasgow outcome score i.e. they were either severely disabled or died during treatment. Glasgow Coma Scale score can be validated as an excellent assessment for monitoring and predicting the prognosis in patients with head injury.

REFERENCES

1. Pruthi N, Ashok M, kumar VS, Jhavar K, Sampath S, Devi BL. Magnitude of pedestrian head injuries and fatalities in Bangalore, South India: A retrospective study from an apex Neurotrauma center. Indian J Med Res.2012;136:1039-43
2. G. Gururaj. “Epidemiology of traumatic brain injuries: Indian scenario”, Neurol Res. Volume 24, Issue 1 (01 January 2002), pp. 24-28.
3. Saini NS et al. Factors predicting outcome in patients with severe head injury: multivariate analysis. Indian Journal of Neurotrauma 9 April 2012. 45-48.
4. Moore L, et al. “Statistical validation of the Glasgow Coma Score.” J Trauma 2006, Jun; 60 (6): 1238-43.
5. Majdan M. “Glasgow Coma Scale Motor Score and Pupillary Reaction to Predict Six-Month mortality in patients with Trauma Brain Injury: Comparison of Field and Admission Assessment.” J of Neurotrauma 2015. Jan 15; 32(2): 101-108
6. NICE: National Institute of Clinical Excellence Clinical Guideline 176.Head Injury (2014): Triage, Assessment, investigation and early management of head injury in children, young people and adults.
7. Jennet B., Teasdale G., Galbraith S., et al. “Severe head injuries in three Countries.” J Neurol Neurosurg Psychiatry 1977; 40: 291-298.
8. Haroon Salaria, Vikar Hussain Qazi. Clinical profile and etiology of craniocerebral trauma patients. MedPulse International Journal of Medicine. May 2019; 10(2): 145- 148.
9. Tandon PN. Management of Head Injury: Fads, Fashions and Facts. Neurology India. 34; 1-20: 1986.
10. Turazzi S, Bricolo A, Pasut ML. Review of 1000 consecutive cases of severe head injury treated before the advent of CT Scanning. Acta Neurochirurgica. 72; 167 -195 : 1984.
11. Sambasivan M. Epidemiology of neurotrauma. Neurology India 1993. 41:3. (Suppl.)
12. Bharti P. Pattern of trauma in western Uttar Pradesh. Neurology India 1993. 41(suppl.) 49-50
13. Mittal B, Milosavljevic B, Rakas FS. Management of severe head injury in Eastern Libya. Neurology India 37: 341 - 348: 1989
14. Mishra HB, Shadangi TN. Predictability of prognosis in head injury using Glasgow Coma Scale as an index.Neurology India, 38; 177 - 182 : 1990.
15. Young, Byron, M.D., et al. “Early prediction of outcome in head-injured patients” Journal of Neurosurgery. March 1981 / Vol. 54.No. 3 / Pages 300-303.
16. Pal, J., Brown, R., and Fleiszer, D. (1989). The value of the Glasgow Coma Scale and Injury Severity Score: Predicting outcome in multiple trauma patients with head injury. Journal of Trauma, 29(6), 746-748.
17. Bishara, S. N., Partridge, F. M., Godfrey, H. P., and Knight, R. G. (1992). Post- traumatic amnesia and Glasgow Coma Scale related to outcome in survivors in a consecutive series of patients with severe closed-head injury. Brain Injury, 6(4), 373-380.
18. Changaris, D. G., McGraw, C. P., Richardson, J. D., Garretson, H. D., Arpin, E. J., and Shields, C. B. (1987).Correlation of cerebral perfusion pressure and Glasgow Coma Scale to outcome. Journal of Trauma, 27(9), 1007-1013.
19. Demetriades D, et al. Outcome and prognostic factors in head injuries with an admission Glasgow coma scale score of 3.Arch Surg.2004oct; 139(10):1066-8.
20. Bansal S, Surve R M, Uthuchellappan R, Umamaheshwara Rao GS, Philip M. Comparison of illness severity scoring systems for mortality prediction in neuroIntensive care unit in India. Journal of Neuroanaesthesiology and Critical Care 2017;4: 42-8.
21. Choi, S. C., Ward, J. D., and Becker, D. P. (1983). Chart for outcome prediction in severe head injury. Journal of Neurosurgery, 59(2), 294-297.
22. Narayan, R. K., Greenberg, R. P., Miller, J. D., Enas, G. G., Choi, S. C., Kishore, P. R., et al. (1981). Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. Journal of Neurosurgery, 54(6), 751-762.
23. Poon, W. S., Zhu, X. L., Ng, S. C., and Wong, G. K. (2005). Predicting one year clinical outcome in traumatic brain injury at the beginning of rehabilitation. Acta Neurochirurgica, 93 (Suppl.), 207-208.
24. Gennarelli TA, Champion HR, Copes WS, Sacco WJ. Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries. J Trauma. 1994 Dec;37(6):962-8.