ACTA NEUROCHIRURGICA
Acta Neurochirurgica 49, 67--79 (1979)
9 by Springer-Verlag 1979
Department of Neurosurgery, Helsinki University Central Hospital, Finland
Outcome Following Head Injuries in the Aged By
J. H e r n e s n i e m i
Summary An analysis of 420 patients 60 or more years of age showed that even very mild brain injuries may be dangerous for the aged. Only one third of 174 patients with cerebral contusion made a useful recovery; of the 101 patients with cerebral contusion unconscious for six hours or more, 78 died, and only 11 made a useful recovery. The outcome in patients with acute intracranial haematomas or depressed skull fractures was poor. Even the aged with brain injuries may benefit from an intensive effort at treatment. This effort should, however, be strictly limited in time. With the present means of treating brain injury it seems futile to use limited intensive treatment resources for an acute brain injury in a patient over 70 years of age who is unconscious on admission. In contrast to acute injuries, subacute and chronic subdural haematomas should be operated on promptly in spite of severe neurological impairment or advanced age.
Introduction T h e high m o r t a l i t y in severe b r a i n injuries in the aged is well k n o w n ; the m o r b i d i t y is also high, a n d few s u r v i v o r s r e t u r n to their earlier activities 1, 2, 4, 7, s, 10--16, 21, 22, 24--2T, 29, ;31 I t seems i r r a t i o n a l to utilize scarce i n t e n s i v e care facilities for this p a t i e n t p o p u l a t i o n if the o u t c o m e c a n n o t be i m p r o v e d 1, 3, ~2, 82, ~8 T h e p u r p o s e of this retrospective s t u d y was t w o f o l d : to assess the late o u t c o m e for p a t i e n t s 60 or m o r e years of age w i t h a w i d e r a n g e of head injuries, a n d to establish criteria for w o r t h w h i l e t r e a t m e n t .
Patients 2,468 patients with head injury were treated in the Department of Neurosurgery, Helsinki University Central Hospital, during the period 1971 to 1975. Four hundred and twenty-four patients (17.2 percent) were 60 or more years of age at the time of injury; all but 4 of these 424 were traced, making records for 420 patients available for detailed analysis and follow up. The diagnosis in the 5*
0 0 0 1 - 6 2 6 8 / 7 9 / 0 0 4 9 / 0 0 6 7 / $ 02.60
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J. Hernesniemi:
four cases that could not be traced was cerebral concussion; all four were in good condition on the day of dis&arge. The ages and sexes of the 420 patients are seen in Table 1. The oldest patient was 91 years old at the time of injury; the average age was 67.6 years. At the time of injury 221 patients were living with family or friends, 164 were living alone, and 35 had no home or were in institutions. The causes of injury in the 420 patients are seen in Table 2.
Methods
Classification of Injuries Minor head injury: no loss of consciousness, no amnesia, no neurological deficit. The reason for admission was frequently more the social circumstances of the patient than any real medical need. Cerebral concussion: loss of consciousness for less than half an hour, amnesia, no neurological deficit. Cerebral contusion: loss of consciousness for more than half an hour or confusion, or both, lasting more than six hours with or without other neurological deficits. Extracerebral haematoma: an extracerebral avascular space at least 10ram thick as measured on cerebral angiography films or at the time of operation. Intracerebral mass lesion: a noticeable local intracerebral mass lesion in cerebral angiography. Acute subdural haematoma: diagnosed or operated on within 72 hours of injury. Subacute subdural haematoma: diagnosed or operated on between 72 hours and three weeks of injury. Chronic subdural haematoma: diagnosed or operated on more than three weeks of injury. Depressed skull fracture: at least one bone fragment dislocated inwards by more than the thickness of the bone. Important extracranial injury: fracture of at least the humerus or lower leg.
Classification of. Consciousness States (cf., Table 6) Alert: orientated or confused conversation, obeys commands. Verbal response at least to pain; inappropriate words spontaneously or on pain stimulation, may obey commands, localizes pain. Purposeful response to pain: no words, does not obey commands, localizes pain. Stereotyped response to pain: no words, does not obey commands, does not localize pain. No response to pain: no response to pain, breathing spontaneously. Unconsciousness was defined as the inability to obey commands or to utter recognizable words; eye opening could not be included in the analysis ~0.
Follow-Up Study and Evaluation of Outcome The survivors were followed up from records of hospitals and nursing homes providing further treatment, and by means of questionnaires and telephone calls to the patients, their relatives, or friends. The follow-up study was performed in the first half of 1978. The longest follow-up period was seven years, on average
Outcome Following Head Injuries in the Aged
69
46 months in the patients surviving for more than one month. The Glasgow Outcome Scale was used to classify the results ~7, ~8. Good recovery and moderate disability on the Glasgow Outcome Scale were regarded as useful recoveries.
Results
The results are given in Tables 1-10. All Patients Fifty-nine percent of all patients were men (Table 1), as were 72 percent of the patients with cerebral contusion, intracranial haematoma, depressed skull fracture and gunshot wound. The most common cause of injury in this series was a fall (Table 2). Eightyeight (21 percent) patients smelt of alcohol on admission. Table 1. Age and Sex Distribution in 420 Patients 60 or More Years of Age, With Head Injury Age 60-64 65-69 70-74 75-79 80-84 85
Female years years years years years years
Total
Male
Total
59 45 28 23 13 5
102 68 34 26 11 6
161 113 62 49 24 i1
173
247
420
Table 2. Cause of Head Injury in 420 Patients 60 or More Years of Age Type of injury
Number of patients
Traffic accidents Pedestrians Vehicle occupants Falls Assaults Gunshot wound Unknown
95 55 220 26 6 18
Total
420
Percent
23 13 52.5 6 1.5 4 100
No patient survived in a vegetative state. Half of the 111 deaths (Table 3) occurred during the first 48 hours, and ~/5 during the first month after injury. During the follow up period an additional 88 patients died from other causes not related to the head injury.
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J. Hernesniemi:
Table 3. Outcome in 420 Patients 60 or More Years of Age, With Head Injury Lesion
Outcome 11, 18
Minor head injury Concussion Contusion Gunshot wound Acute subdural haematoma Subacute subdural haematoma Chronic subdural haematoma Intracerebral mass lesion Epidural haematoma Depressed skull fracture All head !n juries
GR
MD
SD
Dead
Total
29 129 34 0 0 10 38 3 0 2 241
0 6 25 1 2 3 4 6 1 2 37
0 8 20 0 2 3 0 3 2 0 31
0 4 95 5 25 7 4 22 5 6 111
29 147 174 6 29 23 46 34 8 10 420
GR = good recovery, MD = moderate disability, SD = severe disability. No patient survived in a vegetative state.
Cerebral Concussion Two patients died from pneumonia and two patients from coronary thrombosis. All eight patients with severe disability were more than 70 years old (Table 3). Cerebral Contusion In the 174 patients in this category, the cause of injury was a traffic accident in 46 percent, a fall in 44 percent, and an assault or other cause in ten percent. Seventy-two percent of the 174 patients were admitted to neuroservice within six hours (Table 4). Table 4. Time Until Admission to Neuroservice in 174 Patients 60 or More Years of Age, With Cerebral Contusion. (Number of patients unconscious for six hours or more in parenthesis) Time of admission
Number of patients
< 6 hours 6-24 hours > 2 4 hours
125 18 31
Total
174 (101)
(77) (11) (13)
Of the 174 patients with cerebral contusion, 76 had the following associated cranial injuries: 29 acute, six subacute, and three chronic subdural haematomas, 34 intracerebral mass lesions, seven epidural
O u t c o m e Following H e a d Injuries in the A g e d
71
haematomas, and eight depressed skull fractures. One patient developed post-traumatic "low pressure hydrocephalus", and a shunt was inserted. Fifteen of the 174 patients had some important extracranial injury. Of the 174 patients with cerebral contusion, 159 underwent the following procedures: carotid angiography in 133, intubation in 100, cranial operation in 48, and tracheostomy in 22 patients. There was a clear difference in the outcome of the patients between the age group 60-69 years and the group 70 years or older. Forty percent of the patients 60-69 years of age made a useful recovery, but only 18 percent of the patients 70 years of age or older did at least reasonably well (Table 5). Table 5. Outcome Related to the Age in 174 Patients 60 or More Years of Age,
With Cerebral Contusion Age
O u t c o m e 17, 18 GR/MD
SD
Dead
Total
60-64 years 65-69 years 70 years
32 18 9
9 4 7
38 23 34
79 45 50
Total
59
20
95
174
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
The outcome was poor when the patient was unconscious on admission (Table 6). No patient with stereotyped response to pain on admission made a useful recovery, and all patients with no response to pain died (Table 6). Table 6. Outcome Related to the Level of Consciousness on Admission in 174 Pa-
tients 60 or More Years of Age, With Cerebral Contusion Level of consciousness
O u t c o m e 17, 18 GR/MD
SD
AIert Verbal response at least to p a i n Purposeful response to pain Stereotyped response to pain N o response to p a i n
34 14 11 0 0
8 4 5 3 0
Total
59
20
Dead t6 24 11 30 14 95
Total 58 42 27 33 14 174
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
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J. Hernesniemi :
Ten of the 174 patients with cerebral contusion died within six hours after injury. Of the remaining 164, 101 patients were unconscious for six hours or more (Table 7). Only 11 of these 101 patients made a useful recovery, 12 are severely disabled, and 78 died (Tables 7 and 10). Three patients, aged 61, 63, and 66 years at the time of injury were unconscious for more than 72 hours but less than one week and made a useful recovery (Table 7). Two of these three had no intracranial complications, and one patient aged 61 years had a temporal intracerebral mass lesion, but recovered without an operation. No patient unconscious for one week or more made a useful recovery (Table 7). Only one patient over 70 years of age and unconscious for six hours or more made a useful recovery (Table 10). This patient was 81 years old at the time of injury, was unconscious for about twelve hours, and had no intracranial complications. Table 7. Outcome Related to the Length of Unconsciousness in 174 Patients
60 or More Years of Age, With Cerebral Contusion Length of unconsciousness
Outcome aT, as GR/MD
SD
Dead
Total
< 6 hours 6-24 hours 24-72 hours 72 hours-7 days ~>7 days
48 6 2 3 0
8 2 6 1 3
17 18 22 11 27
73 26 30 15 30
Total
59
20
95
174
GR = good recovery, MD = moderat e disability, SD = severe disability.
Of the 101 patients unconscious for six hours or more, 46 talked before becoming unconscious. Five of these 46 patients made a useful recovery 7 are severely disabled, and 34 died. Of the 101, 55 had no lucid interval (talked). Of these 55, 6 made a useful recovery, 5 are severely disabled, and 44 died. Few patients with cerebral contusion and intracranial complications recovered well (Table 8). The nine patients over 70 years of age who made a useful recovery had had no intracranial complications (Table 5). Of the 101 patients unconscious for six hours or more, 56 had intracranial complications. Of these 56 patients, 24 had no lucid interval (talked), and all 24 died. Three of the remaining 32 patients with lucid intervals made a useful recovery, 5 are severely disabled, and 24 died.
Outcome Following H e a d Injuries in the Aged
73
Table 8. Outcome Related to the Presence of IntracraniaI Complications (Haematoma, Depressed Skull Fracture) in 174 Patients 60 or More Years of Age, With Cerebral Contusion Intracranial complications
Outcome 17, 28 G R / M D SD
Dead
Yes No
15 44
6 14
55 40
76 98
Total
59
20
95
174
Total
GR = good recovery, M D = moderate disability, SD = severe disability.
Fifteen of the 174 patients with cerebral contusion had an important extracranial injury. Of these 15, 6 made a useful recovery, 4 are severely disabled, and 5 died. Forty-one percent of the men (average age 66.5 years) with cerebral contusion made a useful recovery, but only 20 percent of the women (average age 69 years) did at least reasonably well. Fifty percent of the men and 64 percent of the women with cerebral contusion died. The percentage of patients who died within six hours from injury or were unconscious for six hours or more was higher in women (82 percent) than in men (55 percent). Among the 174 patients with cerebral contusion the outcome was better in patients living with family or friends (average age 66 years) than in patients living alone or with no homes (average age 69 years) (Table 9). The percentages of deaths within six hours after injury or unconsciousness for six hours or more were higher in the patients living alone or with no home (78 and 74 percent) than in the patients living with family or friends (49 percent). No differences in the times until admission to neuroservice could be found among these different groups. Table 9. Outcome Related to the Social Background in 174 Patients 60 or More
Years of Age, With Cerebral Contusion Social background
Outcome 17. is GR/MD
SD
Dead
Total
Living with family or friends Living alone N o home or institutionalized
39 16 4
9 9 2
35 43 I7
83 68 23
Total
59
20
95
174
GR = good recovery, M D = moderate disability, SD = severe disability.
74
J. H e r n esniemi: Table 10. Outcome Related to Age in 101 Patients 60 or More Years of Age,
With Cerebral Contusion and Unconscious for Six Hours or More Age
O u t c o m e iv, is GR/MD
60-64 years 65-69 years 70 years Total
SD
Dead
Total
7 3 1
7 2 3
31 21 26
45 26 30
11
12
78
101
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
Gunshot Wound All six cases were suicide attempts, and all were penetrating injuries. One patient with a lesion of one frontal lobe and the floor of the anterior fossa was operated on because of a cranionasal fistula, and made a useful recovery (Table 3). Acute Subdural Haematorna All patients had cerebral contusion as well. Seven o f the 29 patients with this injury had associated lesions: four intracerebral and two epidural haematomas and three depressed skull fractures. Nine patients were not operated on, two because of their poor condition, and six because of slow cerebral circulation. One patient died before reaching the operating theatre. Sixteen of the 20 patients operated on died. One of these 16, who had been conscious before and after the operation, died from wound infection and meningitis. Two of the four survivors are severely disabled, and two have a moderate disability (Table 3). These latter patients were aged 61 and 67 years at the time of injury and were both alert though disoriented on admission. Subacute SubduraI Haernatoma Of the 23 patients with this injury, six had a cerebral contusion as well. Of these six, one patient aged 64 years had an intracerebral haematoma which was also removed, and he made a useful recovery. Of the 13 patients who made a useful recovery (Table 3), two had a stereotyped response to pain on admission. One patient was not operated on; the haematoma was a small one, but on repeat angiography the haematoma was found to have increased in size. An operation was not, however, considered advisable, and the patient died 17 days after the injury in another hospital.
Outcome Fol!owingHead Injuries in the Aged
75
Chronic SubduraI Haematorna Of the 46 patients with this injury three had had a cerebral contusion, and the others had had concussion, minor head injury, or head injury of unknown severity. Two patients with thin haematomas were not operated on and made a good recovery, as did the majority of the patients who underwent surgery (Table 3). The four deaths in this group occurred as follows. One elderly patient was transferred to another hospital, where she underwent an operation for paralytic ileus. The chronic subdural haematoma was not detected, and the patient died. One patient with stereotyped response to pain before and after the operation died ten days later. One patient who said a few words before the operation remained severely crippled afterwards, and died seven months later from pneumonia. One patient in good condition before and after the operation died two months later in another hospital from subdural empyaema. Four of the total of 46 patients were unconscious on admission; two of these made good recoveries, and two died. Intracerebral Mass Lesion Associated lesions were found in seven of the 34 patients with this injury: one subacute and four acute subdural haematomas, two epidural haematomas, and one depressed skull fracture. Seventeen patients were not operated on; 5 of these made a useful recovery, and 12 died. Seventeen patients were operated on; four of these made a useful recovery, three remained severely disabled, and ten died. Of the nine patients who made a useful recovery (Table 3), one was unconscious but reacted purposefully to pain on admission, four patients responded verbally at least to pain, and four patients were alert. Epidural Haernatoma Eight patients had this type of haematoma. Only one patient aged 77 years had a minor head injury as the primary diagnosis (but was unconscious before the operation and died from profuse bleeding from the sagittal sinus during the operation); all others had cerebral contusions. Only one patient aged 61 years at the time of injury made a useful recovery (Table 3). Depressed Skull Fracture Only two of the ten patients with this injury had cerebral concussion; the other eight had a cerebral contusion as an associated lesion. Of these eight patients, four had altogether three acute sub-
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J. Hernesniemi:
dural haematomas, two intracerebral mass lesions, and one epidural haematoma. The outcome was poor: six patients died (Table 3).
Patients With Tracheostomy A tracheostomy was carried out in 23 patients (22 patients with cerebral contusion and one patient with chronic subdural haematoma), usually on the third day of unconsciousness. Three are alive but moderately disabled, and two are severely disabled 49 and 80 months after injury. Eighteen patients died, 11 of these within one month of injury; the remaining seven were severely disabled until their death from the injury on average nine months later. The longest survival period in these seven patients was 27 months. Discussion
With the present treatment of brain iniury , the following conclusions can be drawn from this series for a country with scarce neurosurgical resources:
Acute Head Injury Minor head injuries, cerebral concussions, and mild cerebral contusions in the aged should be treated energetically to avoid complications such as pneumonia, venous thrombosis, and pulmonary embolism. Patients aged 60-70 years who are not deeply unconscious on admission should be considered for aggressive treatment of intracranial complications and intensive care. If no definite improvement in the level of consciousness is seen within three days after injury, further aggressive treatment such as tracheostomy improves the outcome in very few patients, and there is no hope of a useful recovery after unconsciousness for one week. From a practical point of view prolonged intubation seems to be a reasonable compromise between bad results and scarce resources. Aggressive treatment of intracranial complications and intensive care in patients 70 years of age and unconscious on admission is more or less futile. Patients over 60 years of age who have stereotyped or no responses to pain on admission have almost no hope of making a useful recovery, so no aggressive treatment should be attempted.
Subacute and Chronic Subdural Haematoma In contrast to acute injuries, these haematomas should be operated on promptly in spite of severe neurological impairment or advanced age.
Outcome Following Head Injuries in the Aged
77
The proportion (17.2 percent) of elderly patients in the 2,468 patients with head injury corresponds closely to the proportion (15.6 percent) of the population 60 or more years of age in Finland as a whole 28. Many old patients with head injury die before they can receive neurosurgical care, or are rejected for such care: in the years investigated there were 373 deaths from head injuries in the age groups studied in the catchment area served by the Department of Neurosurgery, Helsinki University Central Hospital 6, as compared with the 111 deaths in this series. These 373 deaths account for 24.9 percent of the deaths from head injuries in all age groups in the catchment area; unfortunately, the incidence of all head injuries in all age groups in the catchment area is not known. Of the population aged 60 years or more in Finland only 38.6 percent are males 28, though 59 percent of the 420 patients in this series, and 72 percent of those severely injured were males. This high proportion of males tallies well with previous reports on head injuries in all age groups 2, 8-16, 23, 27, 29. In this series females were more severely injured than males and their outcome was poorer. The most common cause of injury in the whole series was a fall, but in the cerebral contusion group traffic accidents accounted for an equal number 2, 5, 9, 11, 12, 14-16, 19, 20 The better outcome in patients living with family or friends is due to milder injuries in these patients, and may also be due to better social circumstances and aftercare, or better primary condition. Only one third of the aged patients in this series with a cerebral contusion made a useful recovery (some of these contusions were mild) and 55 percent died 1, ~, 5, s, 12, 19-21, 26, 27, 31. The 80 percent mortality in the patients unconscious for 24 hours or more in this series corresponds well with the results of a study made ten years earlier in the same department 12. The outcome in patients unconstious for six hours or more in this series is very similar to the outcome in Glasgow cases 81. The poor outcome from acute intracranial complications in the aged in this series is in good agreement with earlier reports v, 8, 10-16, 20, 2< 2~, 29 The results of tracheostomy were poor in this series, and in most cases it seemed to prolong life although without any hope of recovery 22, as, ~3 The appalling results of previous over-intensive therapy of aged patients with acute severe brain injury in this department led to a negative over-reaction, so that every effort was not always made in all cases where it should have been. It is my view that one patient with a subacute subdural haematoma would have been saved by a timely operation, and in other instances the treatment left something to be desired. The attitude in this department has been too de-
78
J. Hernesniemi:
spondent regarding the age group 60-70 years; for this age group an intensive effort should be made but this effort should be strictly limited in time. Otherwise we will produce crippled wrecks--"a fate worse than death". References
1. Becker, D. P., Miller, J. D., Ward, J. D., Greenberg, R. P., Young, H. F., Sakalas, R., The outcome from severe head injury with early diagnosis and intensive management. J. Neurosurg. 47 (1977), 491--502. 2. Browne, L. A., Head injuries 1972-73. J. Irish med. Ass. 70 (1977), 197--200. 3. Bruce, D. A., Schut, L., Bruno, L. A., Wood, J. H., Sutton, L. N., Outcome following severe head injuries in children. J. Neurosurg. 48 (1978), 679--688. 4. Brun, H., Der Sch~idelverletzte und sein Schicksal. Bruns' Beitr. klin. Chir. 38 (1903), 192--287, 289--407, 601--691. 5. Carlsson, C.-A., v. Essen, C., L/Sfgren, J., Factors affecting the clinical course of patients with severe head injuries. Part 1: Influence of biological factors. Part 2: Significance of posttraumatic coma. J. Neurosurg. 29 (1968), 242--251. 6. Central Statistical Office of Finland, Statistics on Causes of Death. 7. Fell, D. A., Fitzgerald, S., Moiel, R. H., Caram, P., Acute subdural hematomas. Review of 144 cases. J. Neurosurg. 42 (1975), 37--42. g. Frowein, R. A., Terhaag, D., auf der Haar, K., Friihprognose akuter Hirnsch~idigungen. I. Tell: Bedeutung yon Bewuf~tlosigkeitsdauer und Lebensalter. II. Tell: Die prognostische Bedeutung des neurologischen Syndroms. Katamnestische Ergebnisse iiberlebter langdauernder Bewugtlosigkeit. Akt. Traumatologic 5 (1975), 203--211,291--298. 9. Galbraith, S., Murray, W. R., Patel, A. R., Knill-Jones, R., The relationship between alcohol and head injury and its effect on the conscious level. Brit. J. Surg. 63 (1976), 128--130. 10. Heiskanen, O., Epidural hematoma. Surg. Neurol. 4 (1975), 23--26. 11. Heiskanen, O., Marttila, I., Valtonen, S., Prognosis of depressed skull fracture. Acta chir. scan& 139 (1973), 605--608. 12. Heiskanen, O., Sipponen, P., Prognosis of severe brain injury. Acta neurol. scand. 46 (1970), 343--348. 13. Heiskanen, O., Vapalahti, M., Temporal lobe contusion and haematoma. Acta Neurochir. (Wien) 27 (1972), 29--35. I4. Hooper, R., Observations on extraduraI haemorrhage. Brit. J. Surg. 47 (1959), 71--87. 15. Jamieson, K. G., Yelland, J. D. N., Depressed skull fractures in Australia. J. Neurosurg. 37 (1972), 150--155. 16. Jamieson, K. G., Yelland, J. D. N., Surgically treated traumatic subdural hematomas. J. Neurosurg. 37 (1972), 137--149. 17. Jennett, B., Assessment of the severity of head injury. J. Neurol. Neurosurg. Psychiat. 39 (1976), 647--655. 18. Jennett, B., Bond, M., Assessment of outcome after severe brain damage. A practical scale. Lancet 1 (1975), 480--484. 19. Jennett, B., Teasdale, G., Galbraith, S., Pickard, J., Grant, H., Braakman, R., Avezaat, C., Maas, A., Minderhoud, J., Vecht, C. J., Heiden, J., Small, R., Caton, W., Kurze, T., Severe head injuries in three countries. J. Neurol. Neurosurg. Psychiat. 40 (1977), 291--298. 20. Karimi-Nejad, A., Tritz, W., Das Kopftrauma des alten Menschen. Hefte zur Unfallheilk. 121 (1975), 417--429.
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79
21. Lausberg, G., Kirchh0ff, D., Red0nd0, J. A., Traumatism0s cranianos na idade avan~ada. Arch. Neuro-psiquiat. (S. Paul0) 32 (1974), 104-111. 22. Lewin, W,, Trache0st0my in head injuries. Pr0c. roy. S0c. Med. 52 (1959), 409-411. 23. L0ew, F., Wiistner, D., Diagnose, Behandlung und Pr0gn0se der traumatischen H~imatome des Sch~idelinneren. Acta Neurochir. (Wien), Suppl. VIII, 1960. 24. McKissock, W., Richardson, A., Bloom, W. H., Subdural haematoma. A review of 389 cases. Lancet 1 (1960), 1365--1369. 25. McKissock, W., Taylor, J. C., Bloom, W. H., Till, K., Extradural haematoma. Observations on 125 cases. Lancet 2 (1960), 167--172. 26. Overgaard, J., Christensen, S., Hvid-Hansen, O., Haase, J., Land, A.-M., Htein, O., Pedersen, K. K., Tweed, W. A., Prognosis after head injury based on early clinical examination. Lancet 2 (1973), 631--635. 27. Pazzaglia, P., Frank, G., Frank, F., Gaist, G., Clinical course and prognosis of acute post-traumatic coma. J. Neurol. Neurosurg. Psychiat. 38 (1975), 149--154. 28. Statistical Yearbook of Finland. New Series--72nd--Year 1976, p. 40. Helsinki: Valtion painatuskeskus. 1977. 29. Talalla, A., Morin, M. A., Acute traumatic subdural bematoma: a review of one hundred consecutive cases. J. Trauma 11 (1971), 771--777. 30. Teasdale, G., Jennett, B., Assessment of coma and impaired consciousness. A practical scale. Lancet 2 (1974), 81--84. 31. Teasdale, G., Jennett, B., Assessment and prognosis of coma after head injury. Acta Neurochir. (Wien) 34 (1976), 45--55. 32. Troupp, H., Tracheotomy in brain-injured patients. Eye, Ear, Nose Thr. Monthly 45 (1966), 49--54. 33. Walker, A. E., Black, P., The heroic treatment of acute head injuries: a critical analysis of the results. Amer. Surg. 26 (1960), 184--188. Author's address: J. Hernesniemi, M.D., Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, SF-00260 Helsinki 26, Finland.
Acta Neurochirurgica 49, 67--79 (1979)
9 by Springer-Verlag 1979
Department of Neurosurgery, Helsinki University Central Hospital, Finland
Outcome Following Head Injuries in the Aged By
J. H e r n e s n i e m i
Summary An analysis of 420 patients 60 or more years of age showed that even very mild brain injuries may be dangerous for the aged. Only one third of 174 patients with cerebral contusion made a useful recovery; of the 101 patients with cerebral contusion unconscious for six hours or more, 78 died, and only 11 made a useful recovery. The outcome in patients with acute intracranial haematomas or depressed skull fractures was poor. Even the aged with brain injuries may benefit from an intensive effort at treatment. This effort should, however, be strictly limited in time. With the present means of treating brain injury it seems futile to use limited intensive treatment resources for an acute brain injury in a patient over 70 years of age who is unconscious on admission. In contrast to acute injuries, subacute and chronic subdural haematomas should be operated on promptly in spite of severe neurological impairment or advanced age.
Introduction T h e high m o r t a l i t y in severe b r a i n injuries in the aged is well k n o w n ; the m o r b i d i t y is also high, a n d few s u r v i v o r s r e t u r n to their earlier activities 1, 2, 4, 7, s, 10--16, 21, 22, 24--2T, 29, ;31 I t seems i r r a t i o n a l to utilize scarce i n t e n s i v e care facilities for this p a t i e n t p o p u l a t i o n if the o u t c o m e c a n n o t be i m p r o v e d 1, 3, ~2, 82, ~8 T h e p u r p o s e of this retrospective s t u d y was t w o f o l d : to assess the late o u t c o m e for p a t i e n t s 60 or m o r e years of age w i t h a w i d e r a n g e of head injuries, a n d to establish criteria for w o r t h w h i l e t r e a t m e n t .
Patients 2,468 patients with head injury were treated in the Department of Neurosurgery, Helsinki University Central Hospital, during the period 1971 to 1975. Four hundred and twenty-four patients (17.2 percent) were 60 or more years of age at the time of injury; all but 4 of these 424 were traced, making records for 420 patients available for detailed analysis and follow up. The diagnosis in the 5*
0 0 0 1 - 6 2 6 8 / 7 9 / 0 0 4 9 / 0 0 6 7 / $ 02.60
68
J. Hernesniemi:
four cases that could not be traced was cerebral concussion; all four were in good condition on the day of dis&arge. The ages and sexes of the 420 patients are seen in Table 1. The oldest patient was 91 years old at the time of injury; the average age was 67.6 years. At the time of injury 221 patients were living with family or friends, 164 were living alone, and 35 had no home or were in institutions. The causes of injury in the 420 patients are seen in Table 2.
Methods
Classification of Injuries Minor head injury: no loss of consciousness, no amnesia, no neurological deficit. The reason for admission was frequently more the social circumstances of the patient than any real medical need. Cerebral concussion: loss of consciousness for less than half an hour, amnesia, no neurological deficit. Cerebral contusion: loss of consciousness for more than half an hour or confusion, or both, lasting more than six hours with or without other neurological deficits. Extracerebral haematoma: an extracerebral avascular space at least 10ram thick as measured on cerebral angiography films or at the time of operation. Intracerebral mass lesion: a noticeable local intracerebral mass lesion in cerebral angiography. Acute subdural haematoma: diagnosed or operated on within 72 hours of injury. Subacute subdural haematoma: diagnosed or operated on between 72 hours and three weeks of injury. Chronic subdural haematoma: diagnosed or operated on more than three weeks of injury. Depressed skull fracture: at least one bone fragment dislocated inwards by more than the thickness of the bone. Important extracranial injury: fracture of at least the humerus or lower leg.
Classification of. Consciousness States (cf., Table 6) Alert: orientated or confused conversation, obeys commands. Verbal response at least to pain; inappropriate words spontaneously or on pain stimulation, may obey commands, localizes pain. Purposeful response to pain: no words, does not obey commands, localizes pain. Stereotyped response to pain: no words, does not obey commands, does not localize pain. No response to pain: no response to pain, breathing spontaneously. Unconsciousness was defined as the inability to obey commands or to utter recognizable words; eye opening could not be included in the analysis ~0.
Follow-Up Study and Evaluation of Outcome The survivors were followed up from records of hospitals and nursing homes providing further treatment, and by means of questionnaires and telephone calls to the patients, their relatives, or friends. The follow-up study was performed in the first half of 1978. The longest follow-up period was seven years, on average
Outcome Following Head Injuries in the Aged
69
46 months in the patients surviving for more than one month. The Glasgow Outcome Scale was used to classify the results ~7, ~8. Good recovery and moderate disability on the Glasgow Outcome Scale were regarded as useful recoveries.
Results
The results are given in Tables 1-10. All Patients Fifty-nine percent of all patients were men (Table 1), as were 72 percent of the patients with cerebral contusion, intracranial haematoma, depressed skull fracture and gunshot wound. The most common cause of injury in this series was a fall (Table 2). Eightyeight (21 percent) patients smelt of alcohol on admission. Table 1. Age and Sex Distribution in 420 Patients 60 or More Years of Age, With Head Injury Age 60-64 65-69 70-74 75-79 80-84 85
Female years years years years years years
Total
Male
Total
59 45 28 23 13 5
102 68 34 26 11 6
161 113 62 49 24 i1
173
247
420
Table 2. Cause of Head Injury in 420 Patients 60 or More Years of Age Type of injury
Number of patients
Traffic accidents Pedestrians Vehicle occupants Falls Assaults Gunshot wound Unknown
95 55 220 26 6 18
Total
420
Percent
23 13 52.5 6 1.5 4 100
No patient survived in a vegetative state. Half of the 111 deaths (Table 3) occurred during the first 48 hours, and ~/5 during the first month after injury. During the follow up period an additional 88 patients died from other causes not related to the head injury.
70
J. Hernesniemi:
Table 3. Outcome in 420 Patients 60 or More Years of Age, With Head Injury Lesion
Outcome 11, 18
Minor head injury Concussion Contusion Gunshot wound Acute subdural haematoma Subacute subdural haematoma Chronic subdural haematoma Intracerebral mass lesion Epidural haematoma Depressed skull fracture All head !n juries
GR
MD
SD
Dead
Total
29 129 34 0 0 10 38 3 0 2 241
0 6 25 1 2 3 4 6 1 2 37
0 8 20 0 2 3 0 3 2 0 31
0 4 95 5 25 7 4 22 5 6 111
29 147 174 6 29 23 46 34 8 10 420
GR = good recovery, MD = moderate disability, SD = severe disability. No patient survived in a vegetative state.
Cerebral Concussion Two patients died from pneumonia and two patients from coronary thrombosis. All eight patients with severe disability were more than 70 years old (Table 3). Cerebral Contusion In the 174 patients in this category, the cause of injury was a traffic accident in 46 percent, a fall in 44 percent, and an assault or other cause in ten percent. Seventy-two percent of the 174 patients were admitted to neuroservice within six hours (Table 4). Table 4. Time Until Admission to Neuroservice in 174 Patients 60 or More Years of Age, With Cerebral Contusion. (Number of patients unconscious for six hours or more in parenthesis) Time of admission
Number of patients
< 6 hours 6-24 hours > 2 4 hours
125 18 31
Total
174 (101)
(77) (11) (13)
Of the 174 patients with cerebral contusion, 76 had the following associated cranial injuries: 29 acute, six subacute, and three chronic subdural haematomas, 34 intracerebral mass lesions, seven epidural
O u t c o m e Following H e a d Injuries in the A g e d
71
haematomas, and eight depressed skull fractures. One patient developed post-traumatic "low pressure hydrocephalus", and a shunt was inserted. Fifteen of the 174 patients had some important extracranial injury. Of the 174 patients with cerebral contusion, 159 underwent the following procedures: carotid angiography in 133, intubation in 100, cranial operation in 48, and tracheostomy in 22 patients. There was a clear difference in the outcome of the patients between the age group 60-69 years and the group 70 years or older. Forty percent of the patients 60-69 years of age made a useful recovery, but only 18 percent of the patients 70 years of age or older did at least reasonably well (Table 5). Table 5. Outcome Related to the Age in 174 Patients 60 or More Years of Age,
With Cerebral Contusion Age
O u t c o m e 17, 18 GR/MD
SD
Dead
Total
60-64 years 65-69 years 70 years
32 18 9
9 4 7
38 23 34
79 45 50
Total
59
20
95
174
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
The outcome was poor when the patient was unconscious on admission (Table 6). No patient with stereotyped response to pain on admission made a useful recovery, and all patients with no response to pain died (Table 6). Table 6. Outcome Related to the Level of Consciousness on Admission in 174 Pa-
tients 60 or More Years of Age, With Cerebral Contusion Level of consciousness
O u t c o m e 17, 18 GR/MD
SD
AIert Verbal response at least to p a i n Purposeful response to pain Stereotyped response to pain N o response to p a i n
34 14 11 0 0
8 4 5 3 0
Total
59
20
Dead t6 24 11 30 14 95
Total 58 42 27 33 14 174
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
72
J. Hernesniemi :
Ten of the 174 patients with cerebral contusion died within six hours after injury. Of the remaining 164, 101 patients were unconscious for six hours or more (Table 7). Only 11 of these 101 patients made a useful recovery, 12 are severely disabled, and 78 died (Tables 7 and 10). Three patients, aged 61, 63, and 66 years at the time of injury were unconscious for more than 72 hours but less than one week and made a useful recovery (Table 7). Two of these three had no intracranial complications, and one patient aged 61 years had a temporal intracerebral mass lesion, but recovered without an operation. No patient unconscious for one week or more made a useful recovery (Table 7). Only one patient over 70 years of age and unconscious for six hours or more made a useful recovery (Table 10). This patient was 81 years old at the time of injury, was unconscious for about twelve hours, and had no intracranial complications. Table 7. Outcome Related to the Length of Unconsciousness in 174 Patients
60 or More Years of Age, With Cerebral Contusion Length of unconsciousness
Outcome aT, as GR/MD
SD
Dead
Total
< 6 hours 6-24 hours 24-72 hours 72 hours-7 days ~>7 days
48 6 2 3 0
8 2 6 1 3
17 18 22 11 27
73 26 30 15 30
Total
59
20
95
174
GR = good recovery, MD = moderat e disability, SD = severe disability.
Of the 101 patients unconscious for six hours or more, 46 talked before becoming unconscious. Five of these 46 patients made a useful recovery 7 are severely disabled, and 34 died. Of the 101, 55 had no lucid interval (talked). Of these 55, 6 made a useful recovery, 5 are severely disabled, and 44 died. Few patients with cerebral contusion and intracranial complications recovered well (Table 8). The nine patients over 70 years of age who made a useful recovery had had no intracranial complications (Table 5). Of the 101 patients unconscious for six hours or more, 56 had intracranial complications. Of these 56 patients, 24 had no lucid interval (talked), and all 24 died. Three of the remaining 32 patients with lucid intervals made a useful recovery, 5 are severely disabled, and 24 died.
Outcome Following H e a d Injuries in the Aged
73
Table 8. Outcome Related to the Presence of IntracraniaI Complications (Haematoma, Depressed Skull Fracture) in 174 Patients 60 or More Years of Age, With Cerebral Contusion Intracranial complications
Outcome 17, 28 G R / M D SD
Dead
Yes No
15 44
6 14
55 40
76 98
Total
59
20
95
174
Total
GR = good recovery, M D = moderate disability, SD = severe disability.
Fifteen of the 174 patients with cerebral contusion had an important extracranial injury. Of these 15, 6 made a useful recovery, 4 are severely disabled, and 5 died. Forty-one percent of the men (average age 66.5 years) with cerebral contusion made a useful recovery, but only 20 percent of the women (average age 69 years) did at least reasonably well. Fifty percent of the men and 64 percent of the women with cerebral contusion died. The percentage of patients who died within six hours from injury or were unconscious for six hours or more was higher in women (82 percent) than in men (55 percent). Among the 174 patients with cerebral contusion the outcome was better in patients living with family or friends (average age 66 years) than in patients living alone or with no homes (average age 69 years) (Table 9). The percentages of deaths within six hours after injury or unconsciousness for six hours or more were higher in the patients living alone or with no home (78 and 74 percent) than in the patients living with family or friends (49 percent). No differences in the times until admission to neuroservice could be found among these different groups. Table 9. Outcome Related to the Social Background in 174 Patients 60 or More
Years of Age, With Cerebral Contusion Social background
Outcome 17. is GR/MD
SD
Dead
Total
Living with family or friends Living alone N o home or institutionalized
39 16 4
9 9 2
35 43 I7
83 68 23
Total
59
20
95
174
GR = good recovery, M D = moderate disability, SD = severe disability.
74
J. H e r n esniemi: Table 10. Outcome Related to Age in 101 Patients 60 or More Years of Age,
With Cerebral Contusion and Unconscious for Six Hours or More Age
O u t c o m e iv, is GR/MD
60-64 years 65-69 years 70 years Total
SD
Dead
Total
7 3 1
7 2 3
31 21 26
45 26 30
11
12
78
101
G R = good recovery, M D = m o d e r a t e disability, SD = severe disability.
Gunshot Wound All six cases were suicide attempts, and all were penetrating injuries. One patient with a lesion of one frontal lobe and the floor of the anterior fossa was operated on because of a cranionasal fistula, and made a useful recovery (Table 3). Acute Subdural Haematorna All patients had cerebral contusion as well. Seven o f the 29 patients with this injury had associated lesions: four intracerebral and two epidural haematomas and three depressed skull fractures. Nine patients were not operated on, two because of their poor condition, and six because of slow cerebral circulation. One patient died before reaching the operating theatre. Sixteen of the 20 patients operated on died. One of these 16, who had been conscious before and after the operation, died from wound infection and meningitis. Two of the four survivors are severely disabled, and two have a moderate disability (Table 3). These latter patients were aged 61 and 67 years at the time of injury and were both alert though disoriented on admission. Subacute SubduraI Haernatoma Of the 23 patients with this injury, six had a cerebral contusion as well. Of these six, one patient aged 64 years had an intracerebral haematoma which was also removed, and he made a useful recovery. Of the 13 patients who made a useful recovery (Table 3), two had a stereotyped response to pain on admission. One patient was not operated on; the haematoma was a small one, but on repeat angiography the haematoma was found to have increased in size. An operation was not, however, considered advisable, and the patient died 17 days after the injury in another hospital.
Outcome Fol!owingHead Injuries in the Aged
75
Chronic SubduraI Haematorna Of the 46 patients with this injury three had had a cerebral contusion, and the others had had concussion, minor head injury, or head injury of unknown severity. Two patients with thin haematomas were not operated on and made a good recovery, as did the majority of the patients who underwent surgery (Table 3). The four deaths in this group occurred as follows. One elderly patient was transferred to another hospital, where she underwent an operation for paralytic ileus. The chronic subdural haematoma was not detected, and the patient died. One patient with stereotyped response to pain before and after the operation died ten days later. One patient who said a few words before the operation remained severely crippled afterwards, and died seven months later from pneumonia. One patient in good condition before and after the operation died two months later in another hospital from subdural empyaema. Four of the total of 46 patients were unconscious on admission; two of these made good recoveries, and two died. Intracerebral Mass Lesion Associated lesions were found in seven of the 34 patients with this injury: one subacute and four acute subdural haematomas, two epidural haematomas, and one depressed skull fracture. Seventeen patients were not operated on; 5 of these made a useful recovery, and 12 died. Seventeen patients were operated on; four of these made a useful recovery, three remained severely disabled, and ten died. Of the nine patients who made a useful recovery (Table 3), one was unconscious but reacted purposefully to pain on admission, four patients responded verbally at least to pain, and four patients were alert. Epidural Haernatoma Eight patients had this type of haematoma. Only one patient aged 77 years had a minor head injury as the primary diagnosis (but was unconscious before the operation and died from profuse bleeding from the sagittal sinus during the operation); all others had cerebral contusions. Only one patient aged 61 years at the time of injury made a useful recovery (Table 3). Depressed Skull Fracture Only two of the ten patients with this injury had cerebral concussion; the other eight had a cerebral contusion as an associated lesion. Of these eight patients, four had altogether three acute sub-
76
J. Hernesniemi:
dural haematomas, two intracerebral mass lesions, and one epidural haematoma. The outcome was poor: six patients died (Table 3).
Patients With Tracheostomy A tracheostomy was carried out in 23 patients (22 patients with cerebral contusion and one patient with chronic subdural haematoma), usually on the third day of unconsciousness. Three are alive but moderately disabled, and two are severely disabled 49 and 80 months after injury. Eighteen patients died, 11 of these within one month of injury; the remaining seven were severely disabled until their death from the injury on average nine months later. The longest survival period in these seven patients was 27 months. Discussion
With the present treatment of brain iniury , the following conclusions can be drawn from this series for a country with scarce neurosurgical resources:
Acute Head Injury Minor head injuries, cerebral concussions, and mild cerebral contusions in the aged should be treated energetically to avoid complications such as pneumonia, venous thrombosis, and pulmonary embolism. Patients aged 60-70 years who are not deeply unconscious on admission should be considered for aggressive treatment of intracranial complications and intensive care. If no definite improvement in the level of consciousness is seen within three days after injury, further aggressive treatment such as tracheostomy improves the outcome in very few patients, and there is no hope of a useful recovery after unconsciousness for one week. From a practical point of view prolonged intubation seems to be a reasonable compromise between bad results and scarce resources. Aggressive treatment of intracranial complications and intensive care in patients 70 years of age and unconscious on admission is more or less futile. Patients over 60 years of age who have stereotyped or no responses to pain on admission have almost no hope of making a useful recovery, so no aggressive treatment should be attempted.
Subacute and Chronic Subdural Haematoma In contrast to acute injuries, these haematomas should be operated on promptly in spite of severe neurological impairment or advanced age.
Outcome Following Head Injuries in the Aged
77
The proportion (17.2 percent) of elderly patients in the 2,468 patients with head injury corresponds closely to the proportion (15.6 percent) of the population 60 or more years of age in Finland as a whole 28. Many old patients with head injury die before they can receive neurosurgical care, or are rejected for such care: in the years investigated there were 373 deaths from head injuries in the age groups studied in the catchment area served by the Department of Neurosurgery, Helsinki University Central Hospital 6, as compared with the 111 deaths in this series. These 373 deaths account for 24.9 percent of the deaths from head injuries in all age groups in the catchment area; unfortunately, the incidence of all head injuries in all age groups in the catchment area is not known. Of the population aged 60 years or more in Finland only 38.6 percent are males 28, though 59 percent of the 420 patients in this series, and 72 percent of those severely injured were males. This high proportion of males tallies well with previous reports on head injuries in all age groups 2, 8-16, 23, 27, 29. In this series females were more severely injured than males and their outcome was poorer. The most common cause of injury in the whole series was a fall, but in the cerebral contusion group traffic accidents accounted for an equal number 2, 5, 9, 11, 12, 14-16, 19, 20 The better outcome in patients living with family or friends is due to milder injuries in these patients, and may also be due to better social circumstances and aftercare, or better primary condition. Only one third of the aged patients in this series with a cerebral contusion made a useful recovery (some of these contusions were mild) and 55 percent died 1, ~, 5, s, 12, 19-21, 26, 27, 31. The 80 percent mortality in the patients unconscious for 24 hours or more in this series corresponds well with the results of a study made ten years earlier in the same department 12. The outcome in patients unconstious for six hours or more in this series is very similar to the outcome in Glasgow cases 81. The poor outcome from acute intracranial complications in the aged in this series is in good agreement with earlier reports v, 8, 10-16, 20, 2< 2~, 29 The results of tracheostomy were poor in this series, and in most cases it seemed to prolong life although without any hope of recovery 22, as, ~3 The appalling results of previous over-intensive therapy of aged patients with acute severe brain injury in this department led to a negative over-reaction, so that every effort was not always made in all cases where it should have been. It is my view that one patient with a subacute subdural haematoma would have been saved by a timely operation, and in other instances the treatment left something to be desired. The attitude in this department has been too de-
78
J. Hernesniemi:
spondent regarding the age group 60-70 years; for this age group an intensive effort should be made but this effort should be strictly limited in time. Otherwise we will produce crippled wrecks--"a fate worse than death". References
1. Becker, D. P., Miller, J. D., Ward, J. D., Greenberg, R. P., Young, H. F., Sakalas, R., The outcome from severe head injury with early diagnosis and intensive management. J. Neurosurg. 47 (1977), 491--502. 2. Browne, L. A., Head injuries 1972-73. J. Irish med. Ass. 70 (1977), 197--200. 3. Bruce, D. A., Schut, L., Bruno, L. A., Wood, J. H., Sutton, L. N., Outcome following severe head injuries in children. J. Neurosurg. 48 (1978), 679--688. 4. Brun, H., Der Sch~idelverletzte und sein Schicksal. Bruns' Beitr. klin. Chir. 38 (1903), 192--287, 289--407, 601--691. 5. Carlsson, C.-A., v. Essen, C., L/Sfgren, J., Factors affecting the clinical course of patients with severe head injuries. Part 1: Influence of biological factors. Part 2: Significance of posttraumatic coma. J. Neurosurg. 29 (1968), 242--251. 6. Central Statistical Office of Finland, Statistics on Causes of Death. 7. Fell, D. A., Fitzgerald, S., Moiel, R. H., Caram, P., Acute subdural hematomas. Review of 144 cases. J. Neurosurg. 42 (1975), 37--42. g. Frowein, R. A., Terhaag, D., auf der Haar, K., Friihprognose akuter Hirnsch~idigungen. I. Tell: Bedeutung yon Bewuf~tlosigkeitsdauer und Lebensalter. II. Tell: Die prognostische Bedeutung des neurologischen Syndroms. Katamnestische Ergebnisse iiberlebter langdauernder Bewugtlosigkeit. Akt. Traumatologic 5 (1975), 203--211,291--298. 9. Galbraith, S., Murray, W. R., Patel, A. R., Knill-Jones, R., The relationship between alcohol and head injury and its effect on the conscious level. Brit. J. Surg. 63 (1976), 128--130. 10. Heiskanen, O., Epidural hematoma. Surg. Neurol. 4 (1975), 23--26. 11. Heiskanen, O., Marttila, I., Valtonen, S., Prognosis of depressed skull fracture. Acta chir. scan& 139 (1973), 605--608. 12. Heiskanen, O., Sipponen, P., Prognosis of severe brain injury. Acta neurol. scand. 46 (1970), 343--348. 13. Heiskanen, O., Vapalahti, M., Temporal lobe contusion and haematoma. Acta Neurochir. (Wien) 27 (1972), 29--35. I4. Hooper, R., Observations on extraduraI haemorrhage. Brit. J. Surg. 47 (1959), 71--87. 15. Jamieson, K. G., Yelland, J. D. N., Depressed skull fractures in Australia. J. Neurosurg. 37 (1972), 150--155. 16. Jamieson, K. G., Yelland, J. D. N., Surgically treated traumatic subdural hematomas. J. Neurosurg. 37 (1972), 137--149. 17. Jennett, B., Assessment of the severity of head injury. J. Neurol. Neurosurg. Psychiat. 39 (1976), 647--655. 18. Jennett, B., Bond, M., Assessment of outcome after severe brain damage. A practical scale. Lancet 1 (1975), 480--484. 19. Jennett, B., Teasdale, G., Galbraith, S., Pickard, J., Grant, H., Braakman, R., Avezaat, C., Maas, A., Minderhoud, J., Vecht, C. J., Heiden, J., Small, R., Caton, W., Kurze, T., Severe head injuries in three countries. J. Neurol. Neurosurg. Psychiat. 40 (1977), 291--298. 20. Karimi-Nejad, A., Tritz, W., Das Kopftrauma des alten Menschen. Hefte zur Unfallheilk. 121 (1975), 417--429.
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79
21. Lausberg, G., Kirchh0ff, D., Red0nd0, J. A., Traumatism0s cranianos na idade avan~ada. Arch. Neuro-psiquiat. (S. Paul0) 32 (1974), 104-111. 22. Lewin, W,, Trache0st0my in head injuries. Pr0c. roy. S0c. Med. 52 (1959), 409-411. 23. L0ew, F., Wiistner, D., Diagnose, Behandlung und Pr0gn0se der traumatischen H~imatome des Sch~idelinneren. Acta Neurochir. (Wien), Suppl. VIII, 1960. 24. McKissock, W., Richardson, A., Bloom, W. H., Subdural haematoma. A review of 389 cases. Lancet 1 (1960), 1365--1369. 25. McKissock, W., Taylor, J. C., Bloom, W. H., Till, K., Extradural haematoma. Observations on 125 cases. Lancet 2 (1960), 167--172. 26. Overgaard, J., Christensen, S., Hvid-Hansen, O., Haase, J., Land, A.-M., Htein, O., Pedersen, K. K., Tweed, W. A., Prognosis after head injury based on early clinical examination. Lancet 2 (1973), 631--635. 27. Pazzaglia, P., Frank, G., Frank, F., Gaist, G., Clinical course and prognosis of acute post-traumatic coma. J. Neurol. Neurosurg. Psychiat. 38 (1975), 149--154. 28. Statistical Yearbook of Finland. New Series--72nd--Year 1976, p. 40. Helsinki: Valtion painatuskeskus. 1977. 29. Talalla, A., Morin, M. A., Acute traumatic subdural bematoma: a review of one hundred consecutive cases. J. Trauma 11 (1971), 771--777. 30. Teasdale, G., Jennett, B., Assessment of coma and impaired consciousness. A practical scale. Lancet 2 (1974), 81--84. 31. Teasdale, G., Jennett, B., Assessment and prognosis of coma after head injury. Acta Neurochir. (Wien) 34 (1976), 45--55. 32. Troupp, H., Tracheotomy in brain-injured patients. Eye, Ear, Nose Thr. Monthly 45 (1966), 49--54. 33. Walker, A. E., Black, P., The heroic treatment of acute head injuries: a critical analysis of the results. Amer. Surg. 26 (1960), 184--188. Author's address: J. Hernesniemi, M.D., Department of Neurosurgery, Helsinki University Central Hospital, Topeliuksenkatu 5, SF-00260 Helsinki 26, Finland.
