Impact of prognostic factors on outcome in patients with severe head trauma.

here is an obvious need to predict outcome of severe head trauma as early as possible. The era of computerized tomography (CT) and a better understanding of the influence of prognostic factors on the outcome of severe head trauma have materially improved our ability to predict outcome. Age, Glasgow comma score (GCS), CT findings and postoperative complications are strongly associated with outcome. 1 This study was designed to specifically analyze the outcomes associated with individual indicants, which may help in identifying high-risk group for death as well as reducing the complications. We retrospective ly examined patients with severe head trauma that were unable to follow commands after cardiopulmonary resuscitation admitted during the period from June 1995 to December 1996 to the Neurosurgical Department of a 750-bedded tertiary care hospital serving a low socio-economic community located centrally in the metropolitan city of Karachi, Pakistan. Informed consent was taken from hospital authority and approval was taken from the Research Ethics Committee. The patients included in the study were unable to follow commands after successful cardiopulmonary resuscitation, those cases, apneic on arrival and fulfilling the criteria of brain death were excluded. Data was obtained from medical records, CT scan reports, surgeons’ records and patient follow up records. First-day emergency room neurological assessments were also taken into account while analyzing the data. The predictable factors taken into consideration were age, GCS, pupillary response to light described as abnormal only when bilaterally absent, motor response, surgical mass lesion recorded when the patient required craniotomy for evacuation of an intra or extra axial lesion, CT scan findings and non neurological factors such, as somatic injuries and medical complications, postoperative complications including recurrent bleeding, infection and cerebrospinal fluid leakage. Data was reported as mean + standard deviation, percentages, rates and proportions. Chi-square statistics were used for comparison among different categorical predictors and outcome variables. A p value of less than 0.05 was considered to indicate statistical significance. A database was constructed in Microsoft Excel to record all relevant information while analysis was carried out using Epi-Info 6, version 6.02. Out of 199 patients included in the study, 165 (83%) were male and 34 (17%) were female, giving a male to female ratio of 4.85:1. The mean age was 28.9 + 16. The outcome associated with prognostic indicators is summarized in Table 1. Regarding neurosurgical factors, all patients >41 years (53%) had a poor outcome, whereas 70% of patients <20 years of age had a good outcome (p<0.05). Patients with high and low GCS scores showed a significant difference ( p<0.05). Scores between 3 and 5 did well in only 22% while high scores of 9 to 15 showed good outcome in 86%. Surgical decompression was associated with a good outcome in 74% of cases with the first craniotomy while it dropped to 46% with the second craniotomy (p<0.05). In the CT findings, patients with high-density lesions had a good outcome in 67% of cases (p<0.05), however, combined high-density lesions were associated with poorer outcome (only 41% good moderate disability) and a high mortality (p<0.05). Patients with postoperative complications did well in only 43% of cases, while those without complications had a good outcome in 63% cases (p<0.05), and it was depicted with high (48%) mortality rate in patients with complications. Motor posturing was associated with a poorer outcome in 50% of cases (p<0.05). A significant ( p<0.05) downward trend in good outcome was demonstrated in groups of patients with no posturing (64% good outcome), and unilateral or bilateral posturing (36%). Only 31% of patients with impaired pupillary reactions had good outcome, as compared with 65% of those with normal responses (p<0.05). Regarding non-neurosurgical factors, only 17% of patients associated with medical complications made a good recovery (p<0.05). In a group without complications, 65% of patients had a good outcome. Somatic injuries were not good predictors of outcome. There is no single factor that can accurately predict