A new classification of head injury based on computerized tomography

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✓ A new classification of head injury based primarily on information gleaned from the initial computerized tomography (CT) scan is described. It utilizes the status of the mesencephalic cisterns, the degree of midline shift in millimeters, and the presence or absence of one or more surgical masses. The term “diffuse head injury” is divided into four subgroups, defined as follows: Diffuse Injury I includes all diffuse head injuries where there is no visible pathology; Diffuse Injury II includes all diffuse injuries in which the cisterns are present, the midline shift is less than 5 mm, and/or there is no high- or mixed-density lesion of more than 25 cc; Diffuse Injury III includes diffuse injuries with swelling where the cisterns are compressed or absent and the midline shift is 0 to 5 mm with no high- or mixed-density lesion of more than 25 cc; and Diffuse Injury IV includes diffuse injuries with a midline shift of more than 5 mm and with no high- or mixed-density lesion of more than 25 cc. There is a direct relationship between these four diagnostic categories and the mortality rate. Patients suffering diffuse injury with no visible pathology (Diffuse Injury I) have the lowest mortality rate (10%), while the mortality rate in patients suffering diffuse injury with a midline shift (Diffuse Injury IV) is greater than 50%. When used in conjunction with the traditional division of intracranial hemorrhages (extradural, subdural, or intracerebral), this categorization allows a much better assessment of the risk of intracranial hypertension and of a fatal or nonfatal outcome. This more accurate categorization of diffuse head injury, based primarily on the result of the initial CT scan, permits specific subsets of patients to be targeted for specific types of therapy. Patients who would appear to be at low risk based on a clinical examination, but who are known from the CT scan diagnosis to be at high risk, can now be identified.

Article Information

Address reprint requests to: Lawrence F. Marshall, M.D., Division of Neurosurgery, University of California Medical Center, 225 Dickinson Street H-501, San Diego, California 92103–1990.

© AANS, except where prohibited by US copyright law.



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    Computerized tomography scans showing examples of Diffuse Injury II: diffuse injury with limited shift or mass effect (left); diffuse injury with multifocal hemorrhages (center); and diffuse injury marked by deep central hemorrhage (right). The right scan shows a hemorrhage in the midbrain without effacement into the mesencephalic cisterns.

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    Admission computerized tomography scan of a patient with Diffuse Injury III: diffuse injury with swelling, showing virtual obliteration of the cisterns without midline shift or mass effect. This 23-year-old patient was a victim of a motorcycle accident with an admitting Glasgow Coma Scale score of 7.

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    Admission computerized tomography scan of a patient with Diffuse Injury IV: diffuse injury with shift, showing a 22-mm shift of midline from left to right and obliteration of the perimesencephalic cisterns. This 18-year-old man was involved in a motor-vehicle accident and his Glasgow Coma Scale score on admission was 4.

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    Admission computerized tomography scan of a patient in the “evacuated mass lesion” category showing a large intracerebral hemorrhage which required surgical evacuation.

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    Computerized tomography scans of a patient with multiple lesions. Left: Admission scan showing pathology initially not considered to need surgical treatment. Right: Scan obtained 18 hours after admission showing progressive enlargement of both the subdural hematoma and the intracerebral hemorrhage. Based on this appearance, evacuation was carried out.

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    A demonstration of the dynamic aspects of brain injury on the computerized tomography scans of a 26-year-old man who was struck by an automobile. Left: Initial scan showing open cisterns and no midline shift. Right: Follow-up scan obtained 13 hours later showing significant midline shift and development of a surgical subdural hematoma.



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