Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure.

An analysis of clinical signs, singly or in combination, multimodality evoked potentials (MEP's), computerized tomography scans, and intracranial pressure (ICP) data was undertaken prospectively in 133 severely head-injured patients to ascertain the accuracy, reliability, and relative value of these indicants individually, or in various combinations, in predicting one of two categories of outcome. Erroneous predictions, either falsely optimistic (FO) or falsely pessimistic (FP), were analyzed to gain pathophysiological insights into the disease process. Falsely optimistic predictions occurred because of unpredictable complications, whereas FP predictions were due to intrinsic weakness of the indicants as prognosticators. A combination of clinical data, including age, Glasgow Coma Scale (GCS) score, pupillary response, presence of surgical mass lesions, extraocular motility, and motor posturing predicted outcome with 82% accuracy, 43% with over 90% confidence. Nine percent of predictions were FO and 9% FP. The GCS score alone was accurate in 80% of predictions, but at a lower level of confidence (25% at the over-90% level), with 7% FO and 13% FP. Computerized tomography and ICP data in isolation proved to be poor prognostic indicants. When combined individually with clinical data, however, they increased the number of predictions made with over 90% confidence to 52% and 55%, respectively. Data from MEP's represented the most accurate single prognostic indicant, with 91% correct predictions, 25% at the over-90% confidence level. There were no FP errors associated with this indicant. Supplementation of the clinical examination with MEP data yielded optimal prognostic power, an 89% accuracy rate, with 64% over the 90% confidence level and only 4% FP errors. The clinical examination remains the strongest basis for prognosticating outcome in severe head injury, but additional studies enhance the reliability of such predictions.

[1]  L. Marshall,et al.  The outcome with aggressive treatment in severe head injuries. Part I: the significance of intracranial pressure monitoring. , 1979, Journal of neurosurgery.

[2]  J. Selhorst,et al.  Further experience in the management of severe head injury. , 1981, Journal of neurosurgery.

[3]  F. Cordobés,et al.  Prognostic value of the intracranial pressure levels during the acute phase of severe head injuries. , 1979, Acta neurochirurgica. Supplementum.

[4]  J. Habbema,et al.  Systematic selection of prognostic features in patients with severe head injury. , 1980, Neurosurgery.

[5]  M. Rosner,et al.  Significance of intracranial hypertension in severe head injury. , 1977, Journal of neurosurgery.

[6]  B. Jennett,et al.  ASSESSMENT OF OUTCOME AFTER SEVERE BRAIN DAMAGE A Practical Scale , 1975, The Lancet.

[7]  J. Miller,et al.  Evaluation of brain function in severe human head trauma with multimodality evoked potentials. Part 2: Localization of brain dysfunction and correlation with posttraumatic neurological conditions. , 1977, Journal of neurosurgery.

[8]  J. Garlock.  Carcinoma of the oesophagus and upper stomach. , 1947, Lancet.

[9]  I. Frew,et al.  The role of respiratory insufficiency in the mortality of severe head injuries. , 1958, Lancet.

[10]  Randall W. Smith,et al.  The outcome with aggressive treatment in severe head injuries: Part II: Acute and chronic barbiturate administration in the management of head injury , 1979 .

[11]  J. Miller,et al.  The outcome from severe head injury with early diagnosis and intensive management. , 1977, Journal of neurosurgery.

[12]  J. Miller,et al.  CT scan, ICP and early neurological evaluation in the prognosis of severe head injury. , 1979, Acta neurochirurgica. Supplementum.

[13]  C. Carlsson,et al.  Factors Affecting the Clinical Course of Patients with Severe Head Injuries , 1968 .

[14]  W. Tweed,et al.  Prognosis after head injury based on early clinical examination. , 1973, Lancet.

[15]  E. Frost.  The physiopathology of respiration in neurosurgical patients. , 1979, Journal of neurosurgery.

[16]  D. Seales,et al.  Brainstem auditory evoked responses in patients comatose as a result of blunt head trauma. , 1979, The Journal of trauma.

[17]  D. Stablein,et al.  Statistical methods for determining prognosis in severe head injury. , 1980, Neurosurgery.

[18]  J. Desmedt,et al.  Clinical uses of cerebral, brainstem, and spinal somatosensory evoked potentials , 1980 .

[19]  R. Knill-Jones,et al.  The prediction of outcome of patients admitted following head injury in coma with bilateral fixed pupils. , 1979, Acta neurochirurgica. Supplementum.

[20]  S. J. Press,et al.  Choosing between Logistic Regression and Discriminant Analysis , 1978 .

[21]  S. Berrol,et al.  Evoked brain potentials and disability in brain-damaged patients. , 1977, Archives of physical medicine and rehabilitation.

[22]  R. Narayan,et al.  Prognostic implications of early multimodality evoked potentials in severely head-injured patients. A prospective study. , 1981, Journal of Neurosurgery.

[23]  T. Langfitt.  Measuring the outcome from head injuries. , 1978, Journal of neurosurgery.

[24]  G. Gaist,et al.  Clinical course and prognosis of acute post-traumatic coma. , 1975, Journal of neurology, neurosurgery, and psychiatry.

[25]  B Jennett,et al.  PREDICTING OUTCOME IN INDIVIDUAL PATIENTS AFTER SEVERE HEAD INJURY , 1976, The Lancet.

[26]  J. Miller,et al.  The value of serial computerized tomography in the management of severe head injury. , 1979, Surgical neurology.

[27]  J. Miller,et al.  Evaluation of brain function in severe human head trauma with multimodality evoked potentials. Part 1: Evoked brain-injury potentials, methods, and analysis. , 1977, Journal of neurosurgery.

[28]  L. Dorfman,et al.  Electrophysiological localization of central somatosensory lesions in patients with multiple sclerosis. , 1978, Electroencephalography and clinical neurophysiology.

[29]  F. J. Gillingham,et al.  Prognostic signs during continuous monitoring of the ventricular fluid pressure in patients with severe brain injury. , 1979, Acta neurochirurgica. Supplementum.

[30]  B. Jennett,et al.  Assessment of coma and impaired consciousness. A practical scale. , 1974, Lancet.

[31]  R. Narayan,et al.  Early insults to the injured brain. , 1978, JAMA.

[32]  B Jennett,et al.  Severe head injuries in three countries. , 1977, Journal of neurology, neurosurgery, and psychiatry.

[33]  B Jennett,et al.  Prognosis of patients with severe head injury. , 1979, Neurosurgery.

[34]  B. Jennett,et al.  On comparing series of head injured patients. , 1979, Acta neurochirurgica. Supplementum.

[35]  J. Stockard,et al.  Clinical and pathologic correlates of brain stem auditory response abnormalities , 1977, Neurology.

[36]  B Richling,et al.  Predicting outcome after severe head injury--a computer-assisted analysis of neurological symptoms and laboratory values. , 1979, Acta neurochirurgica. Supplementum.

[37]  J. Miller,et al.  Significance of bilateral abnormalities on the CT scan in patients with severe head injury. , 1978, Neurosurgery.

[38]  R. Grossman,et al.  Neurological course and correlated computerized tomography findings after severe closed head injury. , 1980, Journal of neurosurgery.

[39]  L. Marshall,et al.  Outcome in 200 consecutive cases of severe head injury treated in San Diego County: a prospective analysis. , 1980, Neurosurgery.

[40]  B. Jennett,et al.  Avoidable factors contributing to death after head injury. , 1977, British medical journal.