Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation

Clinical article

Restricted access


A Glasgow Coma Scale (GCS) score of 3 on presentation in patients with severe traumatic brain injury due to blunt trauma has been recognized as a bad prognostic factor. The reported mortality rate in these patients is very high, even approaching 100% in the presence of fixed and dilated pupils in some series. Consequently, there is often a tendency to treat these patients less aggressively because of the low expectations for a good recovery. In this paper, the authors' purpose is to report their experience in the management of this patient population, analyzing the mortality rate, prognostic factors, and functional outcome of survivors.


The authors performed a retrospective review of patients who presented between 1997 and 2007 with blunt head trauma and a GCS score of 3. Demographics, mechanism of injury, examination, blood alcohol level, associated injury, intracranial pressure (ICP), surgical procedures, and outcome were all recorded.


A total of 189 patients met the inclusion criteria and were included in this study. The overall mortality rate was 49.2%. At the 6-month follow-up, 13.2% of the entire series achieved a good functional outcome (Glasgow Outcome Scale [GOS] score of 1 or 2).

The patient population was then divided into 2 groups: Group 1 (patients who survived [96]) and Group 2 (patients who died [93]). Patients in Group 1 were younger (mean 33.3 ± 12.8 vs 40.3 ± 16.97 years; p = 0.002) and had lower ICP on admission (mean 16.3 ± 11.1 vs 25.7 ± 12.7 mm Hg; p < 0.001) than those in Group 2. The difference between the 2 groups regarding sex, mechanism of injury, hypotension on admission, alcohol, surgery, and associated injuries was not statistically significant.

The presence of bilateral fixed, dilated pupils was found to be associated with the highest mortality rate (79.7%). Although not statistically significant because of the sample size, pupil status was also a good predictor of the functional outcome at the 6-month follow-up; a good functional outcome (GOS Score 1 or 2) was achieved in 25.5% of patients presenting with bilateral reactive pupils, and 27.6% of patients presenting with a unilateral fixed, dilated pupil, compared with 7.5% for those presenting with bilateral fixed, nondilated pupils, and 1.4% for patients with bilateral fixed, dilated pupils.


Overall, 50.8% of patients survived their injury and 13.2% achieved a good functional outcome after at 6 months of follow-up (GOS Score 1 or 2). Age, ICP on admission, and pupil status were found to be significant predictive factors of outcome. In particular, pupil size and reactivity appeared to be the most important prognostic factor since the mortality rate was 23.5% in the presence of bilateral reactive pupils and 79.7% in the case of bilateral fixed, dilated pupils. The authors believe that patients having suffered traumatic brain injury and present with a GCS score of 3 should still be treated aggressively initially since a good functional outcome can be obtained in some cases.

Abbreviations used in this paper:AIS = Abbreviated Injury Scale; EDH = epidural hematoma; GCS = Glasgow Coma Scale; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; MVA = motor vehicle accident; SDH = subdural hematoma.

Article Information

Address correspondence to: Shankar P. Gopinath, M.D., Department of Neurosurgery, Baylor College of Medicine, 1709 Dryden, Suite 750, Houston, Texas 77030. email:shankarg@bcm.tmc.edu.

Please include this information when citing this paper: published online March 27, 2009; DOI: 10.3171/2009.2.JNS08817.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Diagram showing the overall outcome of the 189 patients with blunt head injury and a GCS score of 3 at presentation. F/U = follow-up.


  • 1

    Alexander E Jr: Global Spine and Head Injury Prevention Project (SHIP). Surg Neurol 38:4784791992

  • 2

    Chesnut RMMarshall LFKlauber MRBlunt BABaldwin NEisenberg HM: The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:2162221993

    • Search Google Scholar
    • Export Citation
  • 3

    Demetriades DKuncir EVelmahos GCRhee PAlo KChan LS: Outcome and prognostic factors in head injuries with an admission Glasgow Coma Scale score of 3. Arch Surg 139:106610682004

    • Search Google Scholar
    • Export Citation
  • 4

    Eisenberg HMGary HE JrAldrich EFSaydjari CTurner BFoulkes MA: Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank. J Neurosurg 73:6886981990

    • Search Google Scholar
    • Export Citation
  • 5

    Fearnside MRCook RJMcDougall PMcNeil RJ: The Westmead Head Injury Project outcome in severe head injury. A comparative analysis of pre-hospital, clinical and CT variables. Br J Neurosurg 7:2672791993

    • Search Google Scholar
    • Export Citation
  • 6

    Gennarelli TAChampion HRCopes WSSacco WJ: Comparison of mortality, morbidity, and severity of 59,713 head injured patients with 114,447 patients with extracranial injuries. J Trauma 37:9629681994

    • Search Google Scholar
    • Export Citation
  • 7

    Goebert HW Jr: Head injury associated with a dilated pupil. Surg Clin North Am 50:4274321970

  • 8

    Kotwica ZJakubowski JK: Head-injured adult patients with GCS of 3 on admission—who have a chance to survive?. Acta Neurochir (Wien) 133:56591995

    • Search Google Scholar
    • Export Citation
  • 9

    Lieberman JDPasquale MDGarcia RCipolle MDMark Li PWasser TE: Use of admission Glasgow Coma Score, pupil size, and pupil reactivity to determine outcome for trauma patients. J Trauma 55:4374422003

    • Search Google Scholar
    • Export Citation
  • 10

    Phuenpathom NChoomuang MRatanalert S: Outcome and outcome prediction in acute subdural hematoma. Surg Neurol 40:22251993

  • 11

    Pickett WArdern CBrison RJ: A population-based study of potential brain injuries requiring emergency care. CMAJ 165:2882922001

  • 12

    Signorini DFAndrews PJJones PAWardlaw JMMiller JD: Predicting survival using simple clinical variables: a case study in traumatic brain injury. J Neurol Neurosurg Psychiatry 66:20251999

    • Search Google Scholar
    • Export Citation
  • 13

    Tien HCCunha JRWu SNChughtai TTremblay LNBrenneman FD: Do trauma patients with a Glasgow Coma Scale score of 3 and bilateral fixed and dilated pupils have any chance of survival?. J Trauma 60:2742782006

    • Search Google Scholar
    • Export Citation
  • 14

    Valadka ABInjury to the Cranium. Mattox KLFeliciano DVMoore EE: Trauma ed 4New YorkMcGraw-Hill2000. 377399

  • 15

    Waxman KSundine MJYoung RF: Is early prediction of outcome in severe head injury possible?. Arch Surg 126:123712421991




All Time Past Year Past 30 Days
Abstract Views 216 215 19
Full Text Views 140 110 1
PDF Downloads 122 105 2
EPUB Downloads 0 0 0


Google Scholar