J Neurosurg 47:491-502, 1977
The outcome from severe head injury with early diagnosis and intensive management DONALD P. BECKER, M.D., J. DOUGLAS MILLER, M.D., PH.D., F.R.C.S., JOHN D . WARD, M . D . , RICHARD P. GREENBERG, M . D . , HAROLD F. YOUNG, M . D . , AND ROMAS SAKALAS, M . D .
Division of Neurological Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia o,' In the belief that secondary cerebral compression, hypoxia, and ischemia materially influence the outcome from severe head injury, a standardized protocol was followed in 160 patients, with emphasis on early diagnosis and evacuation of intracranial mass lesions by craniotomy, artificial ventilation, control of increased intracranial pressure, and aggressive medical therapy. Of these patients, 36% made a good recovery, 24% were moderately disabled, 8% were severely disabled, 2% were vegetative, and 30% died. The mortality rate compares favorably with outcomes in similar patients reported from other centers and there has been no increase in the numbers of severely disabled or vegetative patients. It is proposed that vigorous surgical and medical therapy, by preventing or reversing secondary cerebral insults, enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients. KEY WORDS head injury 9 mass lesion o c u l o c e p h a l i c reflex 9 motor response 9
HE management of patients with severe head injury continues to present neurosurgeons with a major challenge; mortality and morbidity are appallingly high, and detailed neurological and psychosocial follow-up studies reveal that many apparent recoveries are in fact social t r a g e d i e s ? ,1~ A l t h o u g h the p r i m a r y destructive injury to the brain clearly cannot be repaired, the neurosurgical optimist must adopt the stance that if all deleterious seco n d a r y processes could be prevented, reversed, or even halted, then some overall improvement in outcome from the injury should be evident. Ideally, the maximum number of patients whose initial injury had caused sufficiently little brain damage to
T
J. Neurosurg. / Volume 4 7 / October, 1977
9
intensive care
9
leave a potential for recovery should realize that potential and become indepgndent of help from others. Neurological surgeons have resorted to many different forms of surgical therapy to achieve these aims, ranging from burr-hole exploration to massive decompressive craniotomy, and medical therapy including use of steroids, osmotic agents, controlled ventilation, h y p o t h e r m i a , and barbiturates.l.2,4 6,9,16,1S,21,22,26,31A major problem in evaluating these measures is that series are seldom randomized for therapy and no therapy, nor are they large enough to demonstrate significant differences in outcome even if so randomized. Results must therefore be compared with earlier results 491
D. P. Becker, et al. from the same center or with those reported by other centers. It becomes crucial to ensure that groups of patients are comparable with respect to age distribution, neurological status, time seen after injury, and incidence of intracranial mass lesions requiring surgical decompression. Furthermore, a reduction in mortality may be balanced by an equivalent increase in severely disabled patients requiring prolonged and skilled nursing care. The onus, therefore, lies on those reporting results of treating severe head injuries to provide adequate information about the clinical status of the patients and to use a uniform and clear classification of outcome to permit valid comparisons with other reported series. Several years ago, Jennett and his colleagues in Glasgow 14,28 started to document carefully and serially the clinical status of patients with severe head injury and to develop a series of standardized descriptions of consciousness level, neurological signs, and outcome categories. The purpose of this study, which has now expanded to include centers in Holland and the United States, was primarily to determine the feasibility of making an accurate and early prognosis of outcome in individual patients; it has already shown considerable promise in this respect. 12,~5,29A large volume of uniformly classified information on patients has been amassed; the strikingly similar distribution of outcomes in the different centers in the study has encouraged the statement that, in these centers at least, local variations in therapy, such as administration of glucocorticoids, do not apparently influence outcome. Although such a statement is a reasonable conclusion from the data gathered in this study, we feel that it is important that its implication of therapeutic nihilism be placed in perspective. Thus, it is unlikely that in a consecutive series of patients who have severe primary brain damage, any single drug will dramatically influence outcome. It may be, however, that an entire management regime aimed at prevention of secondary brain damage, which may include glucocorticoids and other agents, will be successful in yielding the largest numbers of good recoveries possible, given the degree of primary brain injury for the patients in the series. Four years ago we instituted a standardized protocol for the management of patients with severe head injury. This was based on the con492
cept of earliest possible diagnosis and surgical evacuation of all intracranial mass lesions, and the prevention or detection and treatment of the secondary cerebral insults of hypoxia or brain swelling by artificial ventilation, by continuous monitoring of intracranial pressure (ICP) with treatment of intracranial hypertension by increased ventilation, by cerebrospinal fluid (CSF) drainage, and/or by intravenous mannitol. 1,2 Any cardiopulmonary dysfunction, fluid/electrolyte imbalance, or increase in body temperature was aggressively investigated and treated. The neurological examination was sequentially recorded in a simple but standardized manner with attention to possible signs of brain-stem dysfunction. In addition, all patients have been studied by one or more of the following: ventriculography, angiography, or computerized tomography (CT) scan (in the last 9 months of the investigation). A limited number of patients have also had recordings of multimodality evoked potentials and measurements of cerebral blood flow. Data are now available from 160 patients who either died or have been followed for 3 months or more. In this paper we present the outcome of these patients related to age, neurological status on admission, degree of brain shift, and surgical treatment. To try to determine whether the management protocol has been successful, we contrast our results with several comparable head injury series published recently. We have then reviewed our own protocol to determine whether changes could be made for the better. In separate communications we discuss the results and value of monitoring intracranial pressure '7 and evoked potentials. 7 Clinical Materials and Methods Patient Selection
This series consists of 160 patients with severe head injury who were admitted on the Neurosurgical Service of the Medical College of Virginia Hospital from December, 1972, through April, 1976, within 12 hours of injury (usually within 4 hours). The minimum criterion for entry into this study was that patients were unable to obey simple commands. Patients with coma due to alcohol, drug overdose, or epilepsy were excluded. Also excluded from this series were patients J. Neurosurg. / Volume 4 7 / October, 1977
Intensive management of severe head injury with gunshot wounds of the head and those who on arrival at the hospital were already apneic with the combination of bilateral fixed dilated pupils and no motor response to painful stimuli. In the 160 patients neurological status on admission ranged from inability to obey commands to deep coma with loss of pupillary light reaction, reflex eye movements, and the motor response to pain or an abnormal motor, response.
Clinical Assessment
tant cervical spine injury had oculovestibular responses tested. In this paper we classify responses simply as "intact," which includes suppressed (normal responses in patients who regained consciousness later on) and conjugate "doll's eye" responses, or as "impaired," which includes major impairment or failure of unidirectional medial/lateral reflex movement and total absence of response in comatose patients. In this way we do not consider here unilateral oculomotor palsies in the assessment of overall neurological/consciousness status. This basic neurological evaluation was repeated hourly, then at intervals extending throughout the hospital stay, but in this paper we are concerned with the neurological status on admission and its relation to outcome.
After initial assessment of injuries, endotracheal intubation, and attention to respiratory function and arterial pressure where necessary, neurological evaluation was carried out. Patients were first approached by verbal stimuli. The term "vocal response" includes all sounds uttered in response to verbal Diagnostic Measures or painful stimuli. Motor responses classified Immediately after the first neurological as "purposeful" include obeying verbal comevaluation in the emergency room, each mands (no patients on admission) and localizpatient had a frontal twist-drill hole made and ing painful stimuli; "semi-purposeful" an initial manometric measurement of venresponses are synonymous with organized tricular pressure taken from the frontal horn flexor withdrawal; "decorticate" responses (usually the right). After a steady and indicate abnormal arm flexion accompanied pulsatile recording of pressure had been by an element of pronation and wrist flexion; made, 8 ml of air was injected into the ventri"decerebrate" responses are extensor arm cle and portable anteroposterior and lateral and leg responses to pain with arm pronation radiographs taken with the patient remaining and wrist flexion; a flaccid limb with no in the brow-up position. Patients who had 5 response is self-explanatory. In classifying mm or more shift of the midline structures our results we have distinguished between were referred for immediate surgical explora"posturing," which includes decerebrate and tion and decompression. Those with less shift decorticate responses, and "not posturing," or no shift at all and and normal ventricular which includes all better responses (purpressure (0 to 15 mm Hg or 200 mm H20) poseful and semi-purposeful). When there were transferred to the intensive care unit for was a different response on both sides, for inobservation, continued ICP monitoring, and stance, semi-purposeful on the left and decorlater study by angiography or CT scanning ticate on the right, the patient has been classiwithin 48 hours. Those patients who had fied according to the best response. In elevated ICP (> 15 mm Hg) and little or no analysis of data we have added the five pamidline shift were referred for immediate tients who were flaccid on admission with no angiography, or in the last 9 months of this motor response to pain to the "posturing" study for CT scanning, to exclude bilateral group. balancing lesions. Any patient in the intenThe pupillary light reaction was tested and sive care unit who developed rising ICP not in this communication we differentiate immediately explained by changes in blood merely those patients in whom the light gases or other easily remediable cause was response was bilaterally absent. This includes restudied promptly by arteriography, CT patients with dilated and mid-position pupils scan, or ventriculography. but does not include patients with pin-point pupils in whom a response could not be seen. Surgical Management In most patients oculocephalic responses have All patients referred for immediate surbeen used to test the integrity of reflex oculomotor function. Patients with concomi- gical decompression received intravenous
J. Neurosurg. /Volume 47 / October, 1977
493
D. P. Becker, et al. r - ] - Diffuse brain injury (98 patients)
60
[1
50 t'O)
"6 "6 Z
Intracronial mass lesion (62 patients)
-
40 30 20 I0 0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
Age groups in yeors
FIG. 1. Age distribution in 160 patients with severe head injury.
mannitol (1 gm/kg body weight) on the way to the operating room. A wide craniotomy was carried out in all patients, exposing the frontal and anterior temporal lobe on the appropriate side. After decompression by removal of clot and/or necrotic brain, the bone flap was normally replaced. If not already present, a ventricular catheter or subarachnoid pressure screw was placed for postoperative ICP monitoring in the intensive care unit.
Intensive Care Management All patients were initially artifically ventilated on a volume respirator using a high tidal volume (15 ml/kg body weight) and relatively slow rate (10 to 12 min). Small doses of chlorpromazine (25 mg) and/or morphine (1 to 3 mg) were employed to phase patients into the respirator without paralyzing them. Muscle relaxants were only used for studies requiring immobility, such as CT scanning, and for the patients with severe chest injuries or for those who exhibited severe spontaneous hyperventilation. The minute volume was adjusted to maintain arterial pCO2 at 25 to 35 mm Hg, and FiO~ (fraction of inspired oxygen) adjusted to hold arterial pO2 over 70 mm Hg. All patients received dexamethasone: 10 mg immediately, and 4 mg every 6 hours for at least 3 days. Prophylactic anticonvulsant therapy (phenytoin 100 mg, three times daily) was given to all patients. No attempts were made to induce hypothermia but any increase in body temperature was vigorously treated. 49,4
Increased intracranial pressure was treated when ICP rose and remained over 40 mm Hg, even if there had been no neurological change, or if any increase in ICP was apparently associated with deterioration in the level of consciousness. Later in this study we initiated treatment at lower levels of ICP? 6 To control ICP, ventilation was increased to bring arterial pCO2 down to between 20 and 25 mm Hg, CSF was aspirated or drained from the ventricular catheter against a positive pressure, or intravenous mannitol was given.
Evaluation o f Outcome Patients were classified into five categories according to the outcome at 3 months or more from the time of injury, based on the scheme of Jennett and Bond. 14The categories were good recovery, moderate disability, severe disability, vegetative, and dead. The primary distinction between moderate and severe disability is the capacity of the patient in the former category to care for himself/herself. Where it has been necessary to group patients in different categories together, we have taken good recovery and moderate disability together in one group.
Summary of Cases Diagnostic Groups Based on the early diagnostic studies, 62 of the 160 patients (39%) had intracranial mass lesions that were treated by craniotomy and surgical decompression. Of these 62 cases, 12 patients had acute epidural hematomas, 26
J. Neurosurg. / Volume 4 7 / October, 1977
Intensive m a n a g e m e n t of severe head injury TABLE 1 Clinical features on admission of 160 patients with severe head injury Intracranial Mass Lesion
Factor
No. ~o No. of patients mean age (yrs) vocal response bilaterally unreactive pupils impaired or absent oculocephalic response hemiparesis decorticate, decerebrate, or flaccid
62 33 2
Diffuse Brain Injury
P Value*
No. 7o 98 24 10 10
NS NS
3
Total No. 7o 160 27 12
8
23 37
The outcome from severe head injury with early diagnosis and intensive management DONALD P. BECKER, M.D., J. DOUGLAS MILLER, M.D., PH.D., F.R.C.S., JOHN D . WARD, M . D . , RICHARD P. GREENBERG, M . D . , HAROLD F. YOUNG, M . D . , AND ROMAS SAKALAS, M . D .
Division of Neurological Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia o,' In the belief that secondary cerebral compression, hypoxia, and ischemia materially influence the outcome from severe head injury, a standardized protocol was followed in 160 patients, with emphasis on early diagnosis and evacuation of intracranial mass lesions by craniotomy, artificial ventilation, control of increased intracranial pressure, and aggressive medical therapy. Of these patients, 36% made a good recovery, 24% were moderately disabled, 8% were severely disabled, 2% were vegetative, and 30% died. The mortality rate compares favorably with outcomes in similar patients reported from other centers and there has been no increase in the numbers of severely disabled or vegetative patients. It is proposed that vigorous surgical and medical therapy, by preventing or reversing secondary cerebral insults, enables some patients who would have died to make a good recovery without increasing the proportion of severely disabled patients. KEY WORDS head injury 9 mass lesion o c u l o c e p h a l i c reflex 9 motor response 9
HE management of patients with severe head injury continues to present neurosurgeons with a major challenge; mortality and morbidity are appallingly high, and detailed neurological and psychosocial follow-up studies reveal that many apparent recoveries are in fact social t r a g e d i e s ? ,1~ A l t h o u g h the p r i m a r y destructive injury to the brain clearly cannot be repaired, the neurosurgical optimist must adopt the stance that if all deleterious seco n d a r y processes could be prevented, reversed, or even halted, then some overall improvement in outcome from the injury should be evident. Ideally, the maximum number of patients whose initial injury had caused sufficiently little brain damage to
T
J. Neurosurg. / Volume 4 7 / October, 1977
9
intensive care
9
leave a potential for recovery should realize that potential and become indepgndent of help from others. Neurological surgeons have resorted to many different forms of surgical therapy to achieve these aims, ranging from burr-hole exploration to massive decompressive craniotomy, and medical therapy including use of steroids, osmotic agents, controlled ventilation, h y p o t h e r m i a , and barbiturates.l.2,4 6,9,16,1S,21,22,26,31A major problem in evaluating these measures is that series are seldom randomized for therapy and no therapy, nor are they large enough to demonstrate significant differences in outcome even if so randomized. Results must therefore be compared with earlier results 491
D. P. Becker, et al. from the same center or with those reported by other centers. It becomes crucial to ensure that groups of patients are comparable with respect to age distribution, neurological status, time seen after injury, and incidence of intracranial mass lesions requiring surgical decompression. Furthermore, a reduction in mortality may be balanced by an equivalent increase in severely disabled patients requiring prolonged and skilled nursing care. The onus, therefore, lies on those reporting results of treating severe head injuries to provide adequate information about the clinical status of the patients and to use a uniform and clear classification of outcome to permit valid comparisons with other reported series. Several years ago, Jennett and his colleagues in Glasgow 14,28 started to document carefully and serially the clinical status of patients with severe head injury and to develop a series of standardized descriptions of consciousness level, neurological signs, and outcome categories. The purpose of this study, which has now expanded to include centers in Holland and the United States, was primarily to determine the feasibility of making an accurate and early prognosis of outcome in individual patients; it has already shown considerable promise in this respect. 12,~5,29A large volume of uniformly classified information on patients has been amassed; the strikingly similar distribution of outcomes in the different centers in the study has encouraged the statement that, in these centers at least, local variations in therapy, such as administration of glucocorticoids, do not apparently influence outcome. Although such a statement is a reasonable conclusion from the data gathered in this study, we feel that it is important that its implication of therapeutic nihilism be placed in perspective. Thus, it is unlikely that in a consecutive series of patients who have severe primary brain damage, any single drug will dramatically influence outcome. It may be, however, that an entire management regime aimed at prevention of secondary brain damage, which may include glucocorticoids and other agents, will be successful in yielding the largest numbers of good recoveries possible, given the degree of primary brain injury for the patients in the series. Four years ago we instituted a standardized protocol for the management of patients with severe head injury. This was based on the con492
cept of earliest possible diagnosis and surgical evacuation of all intracranial mass lesions, and the prevention or detection and treatment of the secondary cerebral insults of hypoxia or brain swelling by artificial ventilation, by continuous monitoring of intracranial pressure (ICP) with treatment of intracranial hypertension by increased ventilation, by cerebrospinal fluid (CSF) drainage, and/or by intravenous mannitol. 1,2 Any cardiopulmonary dysfunction, fluid/electrolyte imbalance, or increase in body temperature was aggressively investigated and treated. The neurological examination was sequentially recorded in a simple but standardized manner with attention to possible signs of brain-stem dysfunction. In addition, all patients have been studied by one or more of the following: ventriculography, angiography, or computerized tomography (CT) scan (in the last 9 months of the investigation). A limited number of patients have also had recordings of multimodality evoked potentials and measurements of cerebral blood flow. Data are now available from 160 patients who either died or have been followed for 3 months or more. In this paper we present the outcome of these patients related to age, neurological status on admission, degree of brain shift, and surgical treatment. To try to determine whether the management protocol has been successful, we contrast our results with several comparable head injury series published recently. We have then reviewed our own protocol to determine whether changes could be made for the better. In separate communications we discuss the results and value of monitoring intracranial pressure '7 and evoked potentials. 7 Clinical Materials and Methods Patient Selection
This series consists of 160 patients with severe head injury who were admitted on the Neurosurgical Service of the Medical College of Virginia Hospital from December, 1972, through April, 1976, within 12 hours of injury (usually within 4 hours). The minimum criterion for entry into this study was that patients were unable to obey simple commands. Patients with coma due to alcohol, drug overdose, or epilepsy were excluded. Also excluded from this series were patients J. Neurosurg. / Volume 4 7 / October, 1977
Intensive management of severe head injury with gunshot wounds of the head and those who on arrival at the hospital were already apneic with the combination of bilateral fixed dilated pupils and no motor response to painful stimuli. In the 160 patients neurological status on admission ranged from inability to obey commands to deep coma with loss of pupillary light reaction, reflex eye movements, and the motor response to pain or an abnormal motor, response.
Clinical Assessment
tant cervical spine injury had oculovestibular responses tested. In this paper we classify responses simply as "intact," which includes suppressed (normal responses in patients who regained consciousness later on) and conjugate "doll's eye" responses, or as "impaired," which includes major impairment or failure of unidirectional medial/lateral reflex movement and total absence of response in comatose patients. In this way we do not consider here unilateral oculomotor palsies in the assessment of overall neurological/consciousness status. This basic neurological evaluation was repeated hourly, then at intervals extending throughout the hospital stay, but in this paper we are concerned with the neurological status on admission and its relation to outcome.
After initial assessment of injuries, endotracheal intubation, and attention to respiratory function and arterial pressure where necessary, neurological evaluation was carried out. Patients were first approached by verbal stimuli. The term "vocal response" includes all sounds uttered in response to verbal Diagnostic Measures or painful stimuli. Motor responses classified Immediately after the first neurological as "purposeful" include obeying verbal comevaluation in the emergency room, each mands (no patients on admission) and localizpatient had a frontal twist-drill hole made and ing painful stimuli; "semi-purposeful" an initial manometric measurement of venresponses are synonymous with organized tricular pressure taken from the frontal horn flexor withdrawal; "decorticate" responses (usually the right). After a steady and indicate abnormal arm flexion accompanied pulsatile recording of pressure had been by an element of pronation and wrist flexion; made, 8 ml of air was injected into the ventri"decerebrate" responses are extensor arm cle and portable anteroposterior and lateral and leg responses to pain with arm pronation radiographs taken with the patient remaining and wrist flexion; a flaccid limb with no in the brow-up position. Patients who had 5 response is self-explanatory. In classifying mm or more shift of the midline structures our results we have distinguished between were referred for immediate surgical explora"posturing," which includes decerebrate and tion and decompression. Those with less shift decorticate responses, and "not posturing," or no shift at all and and normal ventricular which includes all better responses (purpressure (0 to 15 mm Hg or 200 mm H20) poseful and semi-purposeful). When there were transferred to the intensive care unit for was a different response on both sides, for inobservation, continued ICP monitoring, and stance, semi-purposeful on the left and decorlater study by angiography or CT scanning ticate on the right, the patient has been classiwithin 48 hours. Those patients who had fied according to the best response. In elevated ICP (> 15 mm Hg) and little or no analysis of data we have added the five pamidline shift were referred for immediate tients who were flaccid on admission with no angiography, or in the last 9 months of this motor response to pain to the "posturing" study for CT scanning, to exclude bilateral group. balancing lesions. Any patient in the intenThe pupillary light reaction was tested and sive care unit who developed rising ICP not in this communication we differentiate immediately explained by changes in blood merely those patients in whom the light gases or other easily remediable cause was response was bilaterally absent. This includes restudied promptly by arteriography, CT patients with dilated and mid-position pupils scan, or ventriculography. but does not include patients with pin-point pupils in whom a response could not be seen. Surgical Management In most patients oculocephalic responses have All patients referred for immediate surbeen used to test the integrity of reflex oculomotor function. Patients with concomi- gical decompression received intravenous
J. Neurosurg. /Volume 47 / October, 1977
493
D. P. Becker, et al. r - ] - Diffuse brain injury (98 patients)
60
[1
50 t'O)
"6 "6 Z
Intracronial mass lesion (62 patients)
-
40 30 20 I0 0-10
11-20
21-30
31-40
41-50
51-60
61-70
71-80
Age groups in yeors
FIG. 1. Age distribution in 160 patients with severe head injury.
mannitol (1 gm/kg body weight) on the way to the operating room. A wide craniotomy was carried out in all patients, exposing the frontal and anterior temporal lobe on the appropriate side. After decompression by removal of clot and/or necrotic brain, the bone flap was normally replaced. If not already present, a ventricular catheter or subarachnoid pressure screw was placed for postoperative ICP monitoring in the intensive care unit.
Intensive Care Management All patients were initially artifically ventilated on a volume respirator using a high tidal volume (15 ml/kg body weight) and relatively slow rate (10 to 12 min). Small doses of chlorpromazine (25 mg) and/or morphine (1 to 3 mg) were employed to phase patients into the respirator without paralyzing them. Muscle relaxants were only used for studies requiring immobility, such as CT scanning, and for the patients with severe chest injuries or for those who exhibited severe spontaneous hyperventilation. The minute volume was adjusted to maintain arterial pCO2 at 25 to 35 mm Hg, and FiO~ (fraction of inspired oxygen) adjusted to hold arterial pO2 over 70 mm Hg. All patients received dexamethasone: 10 mg immediately, and 4 mg every 6 hours for at least 3 days. Prophylactic anticonvulsant therapy (phenytoin 100 mg, three times daily) was given to all patients. No attempts were made to induce hypothermia but any increase in body temperature was vigorously treated. 49,4
Increased intracranial pressure was treated when ICP rose and remained over 40 mm Hg, even if there had been no neurological change, or if any increase in ICP was apparently associated with deterioration in the level of consciousness. Later in this study we initiated treatment at lower levels of ICP? 6 To control ICP, ventilation was increased to bring arterial pCO2 down to between 20 and 25 mm Hg, CSF was aspirated or drained from the ventricular catheter against a positive pressure, or intravenous mannitol was given.
Evaluation o f Outcome Patients were classified into five categories according to the outcome at 3 months or more from the time of injury, based on the scheme of Jennett and Bond. 14The categories were good recovery, moderate disability, severe disability, vegetative, and dead. The primary distinction between moderate and severe disability is the capacity of the patient in the former category to care for himself/herself. Where it has been necessary to group patients in different categories together, we have taken good recovery and moderate disability together in one group.
Summary of Cases Diagnostic Groups Based on the early diagnostic studies, 62 of the 160 patients (39%) had intracranial mass lesions that were treated by craniotomy and surgical decompression. Of these 62 cases, 12 patients had acute epidural hematomas, 26
J. Neurosurg. / Volume 4 7 / October, 1977
Intensive m a n a g e m e n t of severe head injury TABLE 1 Clinical features on admission of 160 patients with severe head injury Intracranial Mass Lesion
Factor
No. ~o No. of patients mean age (yrs) vocal response bilaterally unreactive pupils impaired or absent oculocephalic response hemiparesis decorticate, decerebrate, or flaccid
62 33 2
Diffuse Brain Injury
P Value*
No. 7o 98 24 10 10
NS NS
3
Total No. 7o 160 27 12
8
23 37
