OUTCOME WITH AGGRESSIVE TREATMENT IN SEVERE HEAD-INJURIES .1. SIGNIFICANCE OF INTRACRANIAL-PRESSURE MONITORING

The authors have analyzed the hospital course and outcome in 100 consecutive patients with severe head injuries who either on admission or within 24 to 48 hours of their hospitalization were not verbally responsive and not able to follow commands. All were treated in a uniform manner. Operative intervention was performed immediately in patients with significant extracerebral hematomas or large superficial intracerebral hematomas. Intracranial pressure (ICP) was monitored in all, and in 55 patients treatment with a combination of dexamethasone, hyperventilation (PaCO2 of 25 to 28 mm Hg), mannitol, normothermia, and controlled systemic arterial pressure was required for intracranial hypertension (ICP>15 mm Hg). In 25 patients whose ICP remained significantly elevated (ICP>40 mm Hg for 15 minutes or more), high-dose pentobarbital therapy was used to lower the ICP. Forty-five patients recovered with no or minimal neurological deficit, and returned to their pre-injury occupation (good recovery). Fifteen patients are moderately disabled, four are severely disabled, and eight remain in a persistent vegetative state. The mortality rate was 28%. The favorable outcome in this series suggests that early aggressive surgical treatment, successful control of intracranial hypertension, and careful attention to medical complications can improve the outcome in patients with severe head injuries.