The relationship between several neurological and physiological variables and subsequent outcome was examined in these 160 patients. Our principal conclusions were: 1) Comatose patients with intracranial mass lesions requiring surgical decompression (40% of the series) were older, neurologically worse, more often had raised ICP, and had a poorer outcome than patients who did not require surgery. 2) Mortality rose with age, mainly from the medical complications of prolonged coma. 3) Bilateral absence of the pupil light reflex and impaired or absent oculocephalic responses predicted a poor outcome in all patients; abnormal or absent motor responses were significantly correlated with a poor outcome only in patients requiring surgical decompression. 4) A few patients with the adverse combination of absent pupil light response, impaired oculocephalic response, and abnormal motor responses did well. All of these patients had undergone surgical decompression. 5) Elevated ICP was signicantly related to a poorer outcome. This was true both for patients with mass lesions and for those with diffuse brain injury, although the latter less frequently exhibited high ICP. 6) Half of all deaths in this series were associated with severely elevated ICP which could not be controlled despite hyperventilation, cerebrospinal fluid (CSF) drainage, and intravenous mannitol.
Some criticisms can be leveled at our claim for reduced mortality.8,13,14 The criteria for admission of patients to our study may have permitted inclusion of less severely injured patients, with a presumably better outcome, than the series with which we compared our results. Entry to our series was determined by failure to obey commands or utter recognizable words immediately upon resuscitation of the patient in the emergency room, and did not include the status of eye opening to stimuli. The criteria for the large series of head-injury patients from three different countries (1000 cases) analyzed and reported by Jennett, et al.,12 were: no eye opening to painful stimuli, no verbal response, and failure to obey commands for at least 6 hours following injury or subsequent deterioration.12 (Henceforth in this paper, the data from that multinational group of collaborating centers will be referred to as the International Data Bank: IDB.)
After careful survey of the results of head-injury treatment spanning 50 years, Langfitt14 concluded in 1978 that there was still no conclusive evidence that mortality in comparable cases had been reduced by newer or more aggressive therapies. In doing so he, in effect, issued a challenge to the neurosurgical community to study and classify their head-injury patients in such a way that true comparability of data could be obtained. Since 1976, we have collected prospective data on patients with severe head injury as part of the program of a head-injury clinical research center. Data have been collected in a form that is compatible both with our previous study and with the IDB. Having obtained a complete follow-up review in a greater number of patients than the previous study, we can compare results both with our previous study and with the IDB, and test the validity of our previous conclusions concerning the significance for outcome of neurological status and raised ICP. Assessment of head-injured patients sooner than 6 hours from injury or deterioration and inclusion of patients who have eye opening to painful stimuli have been said to weaken prognostic correlations.10,12 The IDB contains no such patients, and this remains an untested hypothesis. The present study provides an opportunity to test it.