DEFINING THE LIMITS OF SURVIVORSHIP AFTER VERY SEVERE HEAD-INJURY

Background: Reliable prediction of outcome after head injury is a daun ting task, Although previous reports have highlighted the difficulties of determining outcome in the cohort of severe head injury Glasgow Co ma Scale (GCS) score less than or equal to 8), we wondered within the very severely injured population (GCS score 3-5) if a simple combinati on of clinical parameters may be predictive of poor outcome. Methods: All patients admitted to a Level 1 trauma center with a GCS score of 3 to 5 from 1986 to 1991 inclusive (380 patients) were retrospectively reviewed and outcome a minimum of 6 months after injury was determined by chart review or telephone. Results: Follow-up was accomplished in all but five patients (1.3%), Functional survival (nonvegetative) was correlated to admission GCS score, pupillary abnormalities, and age, A s anticipated, overall functional survival was poor (12.5%), and even worse among those evidencing pupillary abnormalities (6.6%), Interesti ngly, there was an absence of survivors in the advanced age decades, w ith the oldest functional survivor of any GCS increasing in a stepwise fashion with increasing coma score, This translated into the oldest s urvivor of a GCS score of 3 being in their chronologic 30s, a score of 4 in their 40s, and a score of 5 in their 50s, Among patients older t han these age decades, that is beyond this simple age/GCS cut-off (32. 8% of cohort), there were no functional survivors (95% confidence inte rval 0, 2.4), Conclusions: Within the population of very severely head injured patients (GCS score 3-5), the simple combination of age and a dmission GCS score appears to predict accurately nonfunctional outcome in almost one third of patients, If confirmed at other centers, this may have wide-ranging implications regarding counseling of families, u tilization of resources, and the design of head injury studies.