Management of Head Injury
The Management of Mild and
Moderate Head injuries
Until recently, most work in the field of
traumatic brain injury has been directed to-
ward an improved understanding of the epi-
demiology, pathophysiology, and manage-
ment of severe head injury. Lesser insults
have traditionally received less attention de-
spite their greater overall incidence. This
emphasis is somewhat understandable be-
cause of the extremely complex manage-
ment required for severely injured patients
as well as the high rates of morbidity and
mortality observed in these cases. In con-
trast, mild or even moderately severe inju-
ries have often been perceived as resulting
in relatively little long-term morbidity and
almost no mortality. At present, however,
there is a greater awareness that significant
sequelae do result after even mild injuries.
T h e vast social and economic consequences
of these complications are also increasingly
appreciated.
Skillful evaluation and management of pa-
tients with mild to moderate injury is impor-
tant for several reasons. First, injuries of
lesser severity comprise the vast majority of
patients seen with traumatic brain injury.
Mild and moderate head injury is perhaps
the most common reason for hospital admis-
sion after trauma. Extensive resources are
From the Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
* Assistant Professor
t Professor and Chairman
Neurosurgery Clinics of North America-Vol. 2, No. 2, April 1991
Dennis G. Vollmer, MD,*
and Ralph G. Dacey, Jr, M D f
used in this context; thus, accurate and effi-
cient management is essential for limiting
costs. Second. a small but significant num-
L,
ber of patients with apparently minor inju-
ries develop complications with potentially
lethal consequences that require urgent
neurosurgical care. The identification of in-
dividualsvat greatest risk for deterioration
requires large amounts of time and money;
however, it is important to recognize that
most serious morbidity and mortality after
mild and moderate head injury is prevent-
able, making these efforts justified. Third,
many patients exhibit persistent symptoms
or neuropsychologic deficits after mild or
moderate head injury resulting in social dys-
function and lost productivity.
EPIDEMIOLOGIC CONSIDERATIONS
The incidence of mild and moderate head
injuries is difficult to determine. First, many
patients with the mildest injuries do not
seek or receive medical care. Many others
are not hospitalized, but are rather evaluated
in emergency rooms or a doctor's office.
These patients may not be accurately in-
cluded in epidemiologic surveys, which fre-
438 Dennis G. Vollmer and Ralph G. Dacey, Jr
quently focus on hospitalized patients. A
second problem relates to the definition of
what constitutes a head injury. We are obvi-
ously concerned with traumatic brain injury,
but many classification systems such as the
International Classification of Diseases
allow inclusion of injuries to maxillofacial
structures or the scalp in the statistics for
head injury. Third, patients in whom a mild
or moderate head injury coexists with severe
extracerebral trauma may be classified ac-
cording to their most severe or complex in-
jury with omission of the head injury. Fi-
nally, specific definitions regarding severity
are often difficult to obtain, so that although
overall incidence may be available, the rela-
tive incidence of the less severe forms of
injury is unknown.
Despite the aforementioned difficulties,
some conclusions can be drawn. Several
studies have attempted to define the overall
incidence of head injury in the United
state^.^, 45, 49-51 Based on these data, the
annual incidence of new cases of head inju-
ries significant enough to require hospital-
ization is approximately 200 patients per
100,000 population. In a study of 1238 hospi-
talized patients, Rime1 e t als3 found 55% of
patients to have sustained a minor injury and
24% to have had an injury of moderate sever-
ity. In a more recent study of 3358 injuries,
including those dead at the scene, mild
brain injuries accounted for more' than
72%.52 Several other studies have also esti-
mated injury severity for hospitalized pa-
tients with mild and moderate injuries ac-
counting for 91% to 95%. 3*40, 51, lo2It can
therefore b e safely assumed that mild inju-
ries account for more than half of all head
injury hospitalizations; moderate injuries
appear to account for at least one fourth.
The causation of mild and moderate inju-
ries is similar to that for severe craniocere-
bra1 trauma. In the report of Rime1 et
vehicular injuries accounted for 46% of mi-
nor injuries, with falls resulting in 23%. For
moderate injuries, 66% were related to a ve-
hicular accident. Less frequent causes for
either degree of severity included sports-
related injury and assault.
The male predominance observed in se-
vere head injury also is noted for mild and
moderate injuries; males appear to be twice
as prone as females. In two series of patients
from central Virginia, males accounted for
65% to 66% of patients admitted with mild or
moderate injuries.20, s3 The patients with
moderate head injury in the series by Rime1
e t als37s4 were somewhat older, from a lower
socioeconomic background, and with a
higher unemployment rate than were the
patients with mild head injury. Alcohol
abuse was also more common in those with
moderate injuries.
CLASSIFICATION OF MILD AND
MODERATE HEAD INJURIES
Up to this point, the terms mild and mod-
erate head injury have been used without
specific definition. Although many physi-
cians might have an intuitive sense regard-
ing what is implied by these terms, consis-
tent use of a standard terminology is
essential to allow groups of patients to be
compared and therapeutic interventions to
be evaluated.
Several classification schemes have been
proposed for the grading of head injury se-
verity (Table 7' 98 These grading sys-
"3
tems are useful for simplifying the triage of
patients with head injuries to the appro-
priate treatment facilities for prognosis de-
velopment and for allowing patients to be
grouped by severity for systematic study.
The clinical assessment of level of con-
sciousness is the indicant of brain injury
used by most of these grading systems. The
validity of this approach may be confirmed
by the close correlation observed between
the severity score and the actual prognosis.
The use of clinical indicants of severity has
several advantages. First, the determina-
tions are simple, prospective, reproducible,
and can be accomplished with little intraob-
server or interobserver variability." Sec-
ond, clinical measures are inexpensive and
can be applied repeatedly throughout the
patient's course of evaluation and treatment.
One disadvantage of basing severity
classification on the initial level of alertness
is that some patients present with altered
consciousness resulting from other causes
such as the ingestion of drugs or alcohol or
the effects of systemic injuries.27 Further-
more, the patient who is unresponsive im-
mediately after injury may rapidly improve
 T h e Management of Mild and Moderate Head lnjuries 439
Table 1. Level of Consciousness: Classijication and Grading Systems*
RANSOHOFF AND
BECKER ET AL' FLEISCHER~~ GRADY COMA SCALE^ GLASGOW COMA SCALE"

I Transient loss of I Alert; responds 1 Drowsy, lethargic, Eye Opening E

consciousness; now immediately to indifferent, spontaneous 4
alert and oriented questions; may be uninterested or to speech 3
without neurologic disoriented and belligerent, and to pain 2
deficit; may have confused; follows uncooperative; does nothing 1
headache, nausea, complex commands not lapse into sleep Best Motor Response M
or vomiting I1 Drowsy, confused, when left obeys 6
I1 Impaired uninterested; does undisturbed localizes 5
consciousness but not lapse into sleep 2 Stuporous, will lapse withdraws 4
able to follow at when undisturbed; into sleep when not abnormal flexion 3
least a simple follows simple disturbed; may be extensor response 2
command; may be commands only disoriented to time, nothing 1
alert, but with a I11 Stuporous; sleeps place, and person Verbal Response V
focal neurologic when not disturbed; 3 Deep stupor, requires oriented 5
deficit responds briskly strong pain to evoke confused 4
I11 Unable to follow even and appropriately to movement conversation
a single simple mildly noxious 4 Does not respond inappropriate words 3
command because stimuli appropriately to any incomprehensible 2
of disordered level IV Deep stupor; responds stimuli; may exhibit sounds
of consciousness; defensively to decerebrate or nothing 1
may use words, but prolonged noxious decorticate Coma Score
inappropriately; stimuli posturing; retains (E+M+V=3to
motor response V Coma; no appropriate deep tendon 15)
varies from response to any reflexes
localizing pain to stimuli, decorticate 5 Does not respond
posturing or nothing and decerebrate appropriately to any
IV No evidence of brain responses included stimuli; flaccid, no
function (brain VI Deep coma; flaccidity; deep tendon
death) no response to any reflexes
stimuli
* Categories are based on initial presentation and provide a simple system for triage ofpatients into amanagement
system appropriate to the degree of their brain injury.
From Dacey RG Jr, Dikmen SS: Mild head injury. I n Cooper PR (ed): Head Injury, ed 2. Baltimore, Williams &
Wilkins, 1987, p 125; with permission.

to a normal neurologic state. The timing of
classification, therefore, is an important vari-
able that must b e considered. Therefore, the
International Data Bank studv41 of severe
head injury required that patiehts be graded
6 or more hours after injury. Conversely, a
small number of patients who initially ap-
pear to have sustained a minor injury subse-
quently deteriorate, having developed a se-
rious neurosurgical complication such as an
extradural mass lesion. Finally, grading sys-
tems based on levels of consciousness are
insensitive to the transient neurologic de-
rangements that accompany milder injuries,
where a relatively rapid return to alertness is
the rule. Nonetheless, such classification
schemes have the practical advantage of al-
lowing the clinician to make an early deci-
sion regarding management based on
readily available patient data.
The Glasgow Coma Scale (GCS) is per-
haps the most widely used of such grading
systems.g8 In the early 1980s the Glasgow
Coma Scale was arbitrarily divided into
three categories by Rime1 et a1.83,84 Patients
who scored less than 8 were designated as
having sustained a severe head injury. Pa-
tients with a GCS score between 9 and 12
were considered to have moderate head in-
juries, and patients with an initial GCS score
between 13 and 15 were designated as hav-
ing minor head injuries.
The relationship between GCS and mor-
tality was reported by Jane and Rime1 in
1982 (Fig. 1).38In this series of 1248 patients
the mortality increased significantly with
lower GCS scores. Although the rise in mor-
tality in the severely injured group is dra-
matic, patients with moderate degrees of in-
jury who are therefore not in coma also have
440 Dennis G. Vollmer and Ralph G. Dacey,Jr.
20
10 l
m _ . ,
3 4 5 6 7 8 9 10 1 1 12 13 14 15
GCS
Figure 1. Mortality by Glasgow Coma Scale score for
a study involving 1248 patients. (From Jane JA, Rime1
RW: Prognosis in head injury. Clin Neurosurg 29:346,
1982; with permission.)
significant rates of mortality. Thus, although
the risk of mortality in milder degrees of
injury is low in comparison to patients with
severe injuries, these deaths occur in a
group of patients who appear eminently sal-
vageable as far as the central nervous system
injury is concerned. From the figure, it is
apparent that there is little difference in
mortality among patients with a GCS score
of 11 to 15. Thus, the present division of
these groups of severity, though useful, is
arbitrary.
Another method of determining the sever-
ity of brain injury is through the assessment
of the duration of posttraumatic amnesia
(PTA). PTA is defined as the time between
the injury and the point at which the patient
has regained anterograde memory. The du-
ration of PTA roughly correlates with injury
severity, as shown in Table 2.42In the con-
text of mild and moderate injuries, the esti-
mation of PTA can be a valuable tool when
Table 2. Classijication of Posttraumatic
Amnesia Duration
Less than 5 minutes Very mild
Less than 1hour Mild
One to 24 hours Moderate
One to 7 days Severe
More than 7 days Very severe
More than 4 weeks Extremely severe
Adapted from Jennett B, Teasdale G: Management of
Head Injuries. Philadelphia, F.A. Davis, 1981.
the duration of unconsciousness was not di-
rectly observed.
Whereas the grading systems previously
described attempt to encompass the entire
spectrum of head injuries, a few schemes
have been specifically designed for the clin-
ical evaluation and grading of the mild con-
cussive injury (Table 3).53,71 The scheme
described by Nelson et a171 for use after
sports-related mild head injuries assists
coaches, trainers, and physicians in the early
management of such patients (see later dis-
r
cussion). This classification scheme and oth-
ers focusing on minor degrees of trauma
emphasize the duration of cognitive im-
pairment rather than the degree.
It is clear, however, that gross clinical
measures of neurologic status and cognitive
function are relatively insensitive to the
types of deficits that characterize the milder
degrees of brain injury. The evaluation of
these cognitive deficits is discussed in a
later segment of this article.
EVALUATION A N D I N I T I A L
MANAGEMENT O F M I L D AND
M O D E R A T E H E A D INJURY
The early evaluation and management of
patients with milder degress of brain injury
does not differ in principle from that for se-
vere injuries. The goals include the as-
sessment of injury severity, the diagnosis
and treatment of associated injuries, and the
prevention of secondary brain injury caused
by intracranial mass, metabolic or hemody-
namic derangement, or intracranial infec-
tion. Although most patients with mild inju-
ries and many with moderate injuries would
make satisfactory recoveries without spe-
cific treatment, a small percentage of pa-
tients in either group have the potential to
develop serious or life-threatening neuro-
surgical complications.
Frequently, the initial clinical assessment
does not allow this small number of high-
risk patients to be differentiated from the
much larger group of low-risk patients.
Therefore, various forms of radiologic imag-
ing or extended periods of medical observa-
tion are used in selected patients. Unfor-
tunately, the criteria for the implementation
of these additional modalities in the man-
 The Management of Mild and Moderate Head Injuries 44 1
Table 3. Classijications of Concussions
TORG~OO KULUND~~ NELSON ET A L ~ ~

Grade 1 Mild Grade 0

"Bell rung" Stunned, dazed Head struck or moved rapidly
Short-term confusion No confusion, dizziness Not stunned or dazed initially
Unsteady gait No nausea, visual disturbance Subsequently reports headache and difficulty
Dazed appearance Feels well after 1 or 2 in concentrating
LOC minutes Grade 1
Posttraumatic amnesia Coordination Stunned or dazed initially
Grade 2 Moderate No LOC or amnesia
Posttraumatic amnesia LOC "Bell rung"
Vertigo Mental confusion Sensorium quickly clears (less than 1 minute)
Grade 3 Retrograde amnesia Grade 2
Posttraumatic amnesia Tinnitus, dizziness Headache, cloudy sensorium > 1 minute
Retrograde amnesia Skill recovery may be rapid No LOC
Vertigo Severe May have tinnitus, amnesia
Grade 4 Longer LOC May be irritable, hyperexcitable, confused,
Immediate, transient Headache, confusion dizzy
LOC Posttraumatic amnesia Grade 3
Grade 5 Retrograde amnesia Loc < 1 minute
Paralytic coma Not comatose (arousable with noxious
Cardiorespiratory arrest stimuli)
Grade 6 Demonstrates grade 2 symptoms during
Death recovery
Grade 4
LOC > 1 minute
Not comatose
Demonstrates grade 2 symptoms during
recovery
Abbreviation: LOC = loss of consciousness.
From Nelson WE, Jane JA, Gieck JH: Minor head injury in sports: A new system ofclassification and management.
Physician and Sportsmedicine 12:103, 1984; with permission.

agement of moderate and mild head injury
are the subject of great controversy.
A discussion of the prehospital manage-
ment of head injuries is found in the article
by Ward. A comprehensive discussion of the
standard evaluation and management of the
trauma patient is beyond the scope of this
article; rather, we highlight specific aspects
of the early management of mild and moder-
ate injuries.
Moderate head injuries frequently occur
in association with trauma to other organ
systems. T h e relative importance of the
craniocerebral injury in relation to other in-
jury may easily be overestimated or under-
estimated. It is therefore essential that the
whole patient be assessed in a rapid but sys-
tematic manner.
I n the patient with brain injury, it is im-
portant to consider the possibility of associ-
ated spinal injury, and precautions should
be taken to immobilize the spine, particu-
larly during transport and initial evaluation.
Although several recent studies have sug-
gested that the incidence of spinal injury in
patients admitted with head injury is lower
than previously t h ~ u g h t ,25'
~ , 28 the conse-
quences of missing an unstable fracture can
be so devastating that a high index of suspi-
cion should be maintained and a cervical
spine radiographic series should be an early
priority. Frequently the moderately injured
patient does not report neck pain in the
presence of serious injury. Other painful in-
juries may also serve to distract the patient
from cervical symptoms. Thus, the clinical
examination of the cervical region must be
considered unreliable in the patient with
moderate head injuries7', 85
Once respiratory and hemodynamic status
are assessed and stabilized, patients with
moderate head injuries, who, by definition,
have an alteration in consciousness, should
be referred for cranial computed tomogra-
phy (CT) scanning. If hemodynamic com-
promise has not been a problem, a CT scan is
the next priority. If diagnostic peritoneal la-
vage is indicated, time can be saved by plac-
 Dennis G. Vollmer and Ralph G. Dacey, Jr.

A Glasgow Coma Scale Score

-
Normal skull x-rays Abnormal skull x-rays Skull x-rays not done
B
Figure 2. A,Glasgow Coma Scale score distribution among 610 patients with minor head injury involved in a study.
B, Frequency of abnormal computed tomography (CT) scans according to skull radiograph results (Normal, ab-
normal or not obtained; n = 610). (From Dacey RG, Alves WM, Rime1 RW, et al: Neurosurgical complications after
apparently minor head injury. J Neurosurg 65:203, 1986; with permission.)

ing the peritoneal catheter, securing it, and
proceeding to CT scan as lavage is carried
out. Subsequent neurosurgical and general
surgical planning can then be made with full
knowledge of the patient's status.
Clearly, hospitalization is indicated for
the patient with a moderate injury regard-
less of the presence of abnormalities on CT.
Further care is directed toward avoiding
secondary injuries. Close neurologic follow-
up is essential, and repeat CT scanning
should be performed if neurologic status
worsens.
Occasionally patients have hemodynamic
instability or evidence of serious intratho-
racic or intra-abdominal injury, requiring
immediate transportation to the operating
room for surgical treatment. Under these cir-
cumstances, the neurosurgeon is faced with
the dilemma of the patient with the potential
 T h e Management of Mild anad Moderate Head Injuries
for deterioration who is under anesthesia
and therefore difficult to assess. In these
cases, whenever possible we advocate ob-
taining skull radiographs. This can often be
done expeditiously in the operating room as
the patient is prepared for surgery. The
presence of a fracture greatly increases the
risk of an intracranial mass lesion and might
prompt the consideration of exploratory burr
holes during the abdominal or thoracic oper-
ation. Alternatively, an intracranial pressure
monitor can be placed if prolonged general
anesthesia is anticipated and if focal or
lateralizing neurologic findings were not
present during the initial evaluation. In ad-
dition, the patient's pupils should be exam-
ined frequently during the course of general
anesthesia, as the development of anisocoria
may be the first sign of an intracranial mass
lesion in an anesthetized patient. It is occa-
sionally observed that as the patient is resus-
citated from shock and the sites of extra-
cranial bleeding are controlled, intracranial
mass lesions become manifest as they en-
large with the increase in cerebral perfusion
pressure. A C T scan should be obtained
after the surgical procedure in any case.
Patients whose GCS is 13 or more are
classified as having sustained a mild head
injury. Most of these patients make a full
recovery without significant sequelae. A few
patients, however, will later prove to have a
major surgical complication of the injury. I n
the mid 1970s, Reilly e t als2 and Rose et alse
called attention to the group of patients with
avoidable complications of head injury,
many of whom were relatively alert soon
after injury and have been described by the
term talk and die.In these patients, death is
not a result of impact damage but rather a
consequence of secondary insults such as
intracranial hematomas or, less commonly,
brain swelling, contusions, ischemia, or
meningitis. That this phenomenon is not a
rare event was shown by Marshall et a1,62
who found that 12% of comatose patients
had a GCS verbal score of 4 or 5 early in their
course.
Mendelow e t a16' noted the development
of intracranial hematomas in 1.3% of 865
alert and oriented patients admitted to the
hospital after a loss of consciousness. In a
prospective series of 610 consecutive pa-
tients with minor head injury (GCS 13 to 15)
443
(Fig. 2) hospitalized at the University of Vir-
ginia, 3% ultimately required a neurosur-
gical procedure (Table 4)." The most fre-
quently observed mass lesion in this series
was an acute subdural hematoma, which is
in agreement with the observation of Reilly
et a1.82
The major problem for the clinician man-
aging minor head injuries involves de-
veloping a management strategy that
prevents delays in treatment of this small
number of intracranial complications with-
out causing excessive rates of hospitaliza-
tion, diagnostic study, inconvenience, or
cost to the majority of patients. The first
question to be asked regarding the patient
with minor head injuries is whether any
brain injury has occurred at all. In the mild-
est form of traumatic brain injury, the con-
cussion, there is by definition a transient al-
teration in neurologic function, with rapid
return to normal or near normal alertness.
The classic description of cerebral con-
cussion involves a transient loss of con-
sciousness that is invariably associated with
some degree of PTA. In these cases, a brain
injury has certainly occurred at least on a
physiologic basis, although some anatomic
damage may also exist.39, 75, 76, 79, Gen-
narelli and Ommaya29,74 have expanded the
clinical spectrum of concussion to include
milder injuries in which consciousness is
preserved but transient confusion or disori-
entation may be observed. There is no asso-
Table 4. Operative Procedures Required i n 610
Patients with Minor Head Injury
PATIENTS
PROCEDURE (4
Elevation of depressed skull fracture 3
Craniotomy for intracranial hematoma 5
Acute subdural hematoma 3
Epidural hematoma 1
Intracerebral hematoma 1
Burr holes for chronic subdural hematoma 1
Intracranial pressure monitor 7
Craniotomy for arachnoid cyst (delayed 1
volumetric decompensation after head
injury)
Craniotomy, extracranial-intracranial 1
anastomosis after left internal carotid
endarterectomy
From Dacey RG, Alves WM, Rime1 RW, et al: Neuro-
surgical complications after apparently minor head in-
jury. J Neurosurg 65:203, 1986; with permission.
444 Dennis G . Vollrner an~dRalph G . Dacey, Jr.
ciated amnesia and no posttraumatic se-
quelae. Slightly more severe concussive
injuries also produce a confused state that
clears, followed in 5 to 10 minutes by retro-
grade amnesia. With still greater severity,
the amnesia develops immediately after im-
pact without a latent interval. A brief inter-
val of PTA may be the only sequel in these
latter patients.
Many nonconcussed patients present to a
physician or emergency department with
simple facial or scalp lacerations. Their
treatment properly consists of repair of the
laceration and appropriate consideration of
an underlying depressed skull fracture or
penetrating injury. Without an indication of
brain injury, further intervention is rarely
warranted. On the other hand, management
of patients who have sustained a concussion
is more complex.
The initial assessment of a concussed pa-
tient should include a brief history of the
circumstances surrounding the injury. Often
the patient is unable to give a coherent ac-
count of how the injury might have oc-
curred. There should be an attempt to quan-
titate the length of anterograde and
retrograde amnesia. A careful neurologic ex-
amination should be performed and clearly
documented.
As cited by Feuerman et a1,2"he presence
of focal findings or an abnormal mental sta-
tus are highly predictive of serious compli-
cations following a mild head injury. It must
be emphasized that a GCS of 15 does not
preclude finding focal neurologic signs or an
alteration in the mental status examination
(e.g., memory impairment). The level of
consciousness and the status of the pupils
should be described as precisely as possible.
Scalp lacerations should be carefully exam-
ined, and if necessary, skull radiographs
should be obtained to exclude the possibil-
ity of an open depressed fracture. It should
be remembered that the mobility of the
scalp often allows a fracture to be well dis-
tanced from the site of laceration.
Sports-related concussive injuries repre-
sent a distinct clinical subset of mild head
injury for several reasons: they are generally
of milder degree, they are not often associ-
ated with other injury, they frequently are
witnessed, and they are often managed by
nonmedical personnel. Furthermore, man-
agement decisions are often influenced by
unique considerations such as the individ-
ual's desire to return to competitive play.
Concussive brain injury is relatively com-
mon in contact sports. An annual incidence
of 19 per 100 high school football players
was found by Gerberich et al,31 accounting
for 24% of all football injuries in their series.
It must be noted that approximately 1.5mil-
lion Americans per year participate in orga-
nized football alone.2 In addition to football
a number of other sports activities, ice
hockey, rugby, lacrosse, equestrian sports,
and skiing, for example, may pose a risk for
head trauma. Although such injuries repre-
sent a very small fraction of the problem of
mild head injury, the neurosurgeon is fre-
quently asked to render opinions, particu-
larly regarding the return of the individual
to competitive activity.
An extensive prospective study of
football-related minor head injury was car-
ried out by Alves et a12 and Barth et a15 at the
University of Virginia. A total of 2350 col-
lege football players from 10 universities
was included in data collection. Neuropsy-
chologic assessments were performed on
players before the season and then serially
after minor head injury. This study provided
evidence that a single mild head injury pro-
duced deficits in information processing and
cognitive function, which were noted within
24 hours of the insult, but that rapid recovery
was observed over the subsequent 5 to
10-day period. Posttraumatic symptom-
atology increased significantly over the pre-
season rate within 24 hours after injury,
but then declined over time and approxi-
mated the preseason rate at about 10 days
after injury.
Based on these data we recommend that
individuals suffering a sports-related mild
head injury of sufficient degree to produce
disorientation or confusion that lasts for sev-
eral minutes should not return to play for 10
days. A patient with a milder injury whose
sensorium clears in less than 1minute may
return to contact activity within 5 days, pro-
vided there is no associated posttraumatic
symptomatology. More severe degrees of in-
jury should be evaluated and managed as
noted earlier. It should be remembered that
little information exists regarding the long-
term effects of such injuries, so any recom-
 The Management of Mild and Moderate Head Injuries
mendations must be viewed for the present
as rough guidelines rather than optimal
management.
Skull Radiography
The role of skull radiographs in the evalu-
ation of patients with minor and perhaps
moderate head injuries continues to gener-
ate COntrOVerSY.lO,17,18,21,26,43,63,77,86,89,96
Several important questions have not been
definitely answered. The first is whether
demonstration of a linear nondepressed
skull fracture is clinically useful, specifi-
cally, whether it predicts risk of neurologic
deterioration and adds to a clinical examina-
tion. Second, if it is useful to demonstrate
fractures radiographically, what criteria
should be used to select patients for study
and what is an acceptable level of error in
selection? Third, should different criteria be
used for different age groups or mechanisms
of injury? And fourth, when fractures are
demonstrated, what is the most efficient
means of further managing the patient both
in terms of safety and cost effectiveness?
445
A number of studies such as those by Bell
and LOO^," ~ h i l l i ~and
s , ~Masters
~ et a1,63
have proposed that patients should be
screened before the performance of skull ra-
diographs and a determination made as to
whether they demonstrate any of a number
of high-yield criteria chosen to decrease the
number of negative studies done.
I n the study of Masters et al,63 patients
were placed into either a low, moderate, or
high-risk group based on clinical criteria
(Table 5). In this extensive study of over
7000 patients with head injuries, only 12
(0.4%) of the 2795 patients in the low-risk
group who had skull radiographs were dem-
onstrated as having a fracture. No patient in
the low-risk group developed an intracranial
complication. The moderate-risk group,
which includes any history of change of con-
sciousness at the time of injury or subse-
quently, demonstrated fractures in 4.2% of
the patients studied radiographically. Three
of 47 moderate-risk patients were found to
have an intracranial injury in association
with a skull fracture. Conversely, 7 of 1074
patients who did not have fractures also had
an intracranial injury later detected. On the

Table 5. Management Strategy for Radiographic Imaging in Head Trauma

LOW RISK GROUP* MODERATE RISK GROUP* HIGH RISK GROUP

Asymptomatic History of change of consciousness Depressed level of consciousness

Headache at time of injury or subsequently not clearly due to alcohol, drugs,
Dizziness History of progressive headache or other cause (e.g., metabolic
Scalp hematoma Alcohol or drug intoxication and seizure disorders)
Scalp laceration Unreliable or inadequate history of Focal neurologic signs
Scalp contusion or abrasion injury Decreasing level of consciousness
Absence of moderate or high-risk Age less than 2 years (unless injury Penetrating skull injury or palpable
criteria very trivial) depressed fracture
Posttraumatic seizure
Vomiting
Posttraumatic amnesia
Multiple trauma
Serious facial injury
Signs of basilar fracture
Possible skull penetration or
depressed fracture
Suspected physical child abuse
Observation alone; discharge with Extended close observation: watch Candidate for neurosurgical consult
head sheet to reliable for signs of high-risk group. or emergency CT examination.
environment; watch for signs of Consider for CT examination or
high- or moderate-risk groups. plain skull radiography; may
require neurosurgical consult.
*Physician assessment of the severity of injury may warrant reassignment to a high-risk group. Any single
criterion from a higher risk group warrants assignment of the patient to the highest risk group applicable.
Adapted from Masters SJ, McClean PM, Arcarese JS, et al: Skull x-ray examinations after head trauma. N Engl J
Med 31654, 1987.
446 Dennis G. Vollmer and Ralph G. Dacey, Jr.
basis of these data, although the moderate-
risk group also has a relatively low likeli-
hood of skull fracture (4.2%),the presence of
a skull fracture confers a nearly tenfold risk
of an intracranial injury. For the study as a
whole, in which radiographs were obtained
for 4068 patients, the risk of an intracranial
mass lesion was nearly 63 times greater for
patients with a skull fracture than for those
without.
Dacey et a120 studied 610 patients with
minor head injury, of whom 583 were stud-
ied with skull radiography. Skull fractures
were observed in 11.1% of patients so exam-
ined. Patients with a fracture were found to
be approximately 20 times more likely to
require neurosurgical intervention than
those without. Rosenthal and ~ e r ~ m a ex- n ~ ' risk of intracranial mass lesion. Further-
amined the role of skull roentgenograms in
pediatric patients after a mild head injury.
They retrospectively studied 459 patients
with normal findings on neurologic exami-
nation, 358 of whom were studied with skull
radiographs. Fractures were noted in 14%
and intracranial complications developed in
1.3%, all in patients with skull fractures. Jen-
nett42 has asserted that a linear fracture
found in a conscious, alert patient increases
the risk of an intracranial hematoma approxi-
mately 400-fold, whereas for patients in
coma, a fracture increases the likelihood of
an intracranial hematoma 20-fold.
More recently, Servadei et alg6 reported
on a prospective analysis of the association
of skull fracture and CT-demonstrated intra-
cranial hematoma. Compiling data from two
different institutions, they demonstrated ap-
proximately a 10% rate of surgical intra-
cranial lesions in patients with skull frac-
tures as opposed to no cases of surgical
intracranial pathology detectable on CT
scan in those without fractures.
Cooper and ~0~~ retrospectively re-
viewed the medical records of 207 patients
with intracranial mass lesions to determine
whether skull radiography altered manage-
ment in any case. They found 16 patients
who were fully alert in the emergency room
who later proved to have a mass lesion. All
but 1of these patients were admitted to the
hospital based on criteria other than the
presence of a skull fracture. One patient,
who was totally intact, was sent home later
to deteriorate. They concluded that only 1of
these 207 patients (0.5%) might have been
managed differently based on the results of
skull radiographs.
Feuerman et a1,23 while conceding that
skull fractures are associated with a greater
risk of a mass lesion, assert that CT scanning
is indicated for all patients with a GCS score
of less than 15 or in any patient with an
abnormal mental status or focal neurologic
finding. Their view is that when CT scan-
ning is used according to these clinical cri-
teria, the information obtained from skull
radiographs is superfluous and does not alter
management.
To summarize these studies, skull frac-
tures are clearly associated with a greater
more, the predictive value of the skull frac-
ture seems to be more robust in the alert
patient than in the patient with a focal deficit
or altered consciousness. Despite this, intra-
cranial complications are relatively infre-
quent, even in the presence of skull fracture.
Furthermore, it would appear that the infor-
mation from skull radiographs alters patient
management less than 1% of the time, rais-
ing questions regarding the efficiency and
cost effectiveness of skull radiography as a
management tool. It must be remembered,
however, that much literature on the sub-
ject has emanated from the United King-
dom where patients with head injury are
often initially evaluated at general hospitals
without CT scanning capability or neuro-
surgical coverage. In this setting, the value
of skull radiography is likely to be much
greater.
Our present approach to the use of skull
films in minor head injury is as follows: Pa-
tients with an altered level of consciousness
(GCS < 15), focal neurologic findings, al-
tered mental status, or other clear indication
for CT scan (e.g., obvious open fracture or
penetrating injury) are first studied by this
modality. Skull radiographs are not obtained
unless indicated by the findings on CT (e.g.,
with the presence of facial fractures, pene-
trating injury, or cerebrospinal fluid (CSF)
leak, or where other additional information
from plain radiographs is required for opera-
tive decision making). Nonconcussed or
mildly concussed patients (Nelson grade 0)
 The Management of Mild a nd Moderate Head Injuries
who are asymptomatic or with minimal
symptoms and without scalp lacerations, are
not subjected to skull radiographs. Skull
radiographs are obtained in concussed pa-
tients in whom CT scanning is not antici-
pated and admission for observation is not
otherwise indicated. In these cases, the
finding of a fracture on a skull radiograph
would significantly alter management. Pre-
viously concussed but alert patients who are
to be admitted to hospital for other indica-
tions are not routinely referred for skull ra-
diographs. It should be emphasized, how-
ever, that in all cases, a low threshold for
obtaining CT scans, not skull films, should
be maintained.
CT and Magnetic Resonance Imaging
Cranial CT has become the mainstay of
the radiographic evaluation of severe head
injuries by allowing a rapid assessment of
potential intracranial pathology. Similarly,
moderate injuries should, under most cir-
cumstances, have a CT scan as part of the
initial evaluation.
The role of CT in minor head injuries is
less well established. Some neurosurgeons
have advocated C T scanning for selected
cases of minor head injury as a means of
excluding an intracranial complication,
thereby allowing discharge of some patients
who would otherwise be admitted for obser-
vation.18 As noted later, such a policy might
prove to be efficient as well as cost effec-
t i ~ e . ~Our
' approach as noted earlier has
been to perform emergent C T scans on all
patients with GCS scores of less than 15 or
patients who have a GCS score of 15 but
with focal neurologic abnormalities, an ab-
normal mental status, or open or penetrating
injury.
The role of magnetic resonance (MR) im-
aging in traumatic brain injury continues to
be clarified.47 Although MR imaging has
greater sensitivity than C T for many paren-
chymal lesions, acute blood is seen well
with CT. Greater availability and shorter
scan times make CT preferable for acute
evaluation. MR imaging, however, may be
useful in the demonstration of subtle lesions
associated with milder degrees of injury,
447
thereby assisting with the determination of
prognosis.54
Hospitalization and Observation
Because the identification of patients at
risk for neurologic deterioration after mild
head injury is difficult based on clinical
grounds alone,24, 86 many neurosurgeons
have advocated a period of hospitalization
for serial neurologic assessment. The cri-
teria for hospital admission vary widely de-
pending on local convention and resource
64 Hospitalization is clearly
indicated for patients with altered level of
consciousness, focal deficits, CSF leak, or
penetrating injuries. The indications for ad-
mission of patients with transient loss of
consciousness who are neurologically nor-
mal are less well established. A group of
British neurosurgeons have advocated skull
radiographs as an aid to clinical decision
making and have provided recommenda-
tions for skull radiographs and hospital ad-
mission policy (Table 6).15
Dacey et a120 examined various policies of
radiologic evaluation and hospital admis-
Table 6 . Recommendations of a Group of
British Neurosurgeons Regarding Management
o f Minor Head Iniuru
INDICATIONS FOR SKULL RADIOGRAPHIC EXAMINATION
AFTER RECENT HEAD INJURY
Loss of consciousness or amnesia at any time
Neurologic symptoms or signs
Cerebrospinal fluid or blood from the nose or ear
Suspected penetrating injury
Scalp bruising or swelling
INDICATIONS FOR ADMISSION TO A GENERAL HOSPITAL*
Confusion or any other depression of the level of
consciousness at the time of examination
Skull fracture
Neurologic symptoms or signs
Difficulty in assessing the patient (e.g., alcohol,
epilepsy, or other medical condition)
Lack of a responsible adult to supervise the patient;
other social problems
* Brief amnesia after trauma with full recovery is not
sufficient indication for admission. Relatives and
friends of patients sent home should receive written
advice about changes that would require the patient to
be returned urgently to hospital.
From Dacey RG Jr, Dikmen SS: Mild head injury. In
Cooper PR (ed): Head injury, ed 2. Baltimore, Williams
& Wilkins, 1987, p 125; with permission.
448 Dennis G. Vollmer and Ralph G. Dacey, Jr.
sion in their series of 610 minor head
injuries. They estimated the costs of three
alternative management plans: (1)hospitali-
zation and observation of all concussed pa-
tients; (2) skull radiographs on all postcon-
cussion patients, with hospitalization of all
those with skull fracture or alteration in
level of consciousness; and ( 3 )CT scans on
all alert concussed patients (GCS 15) and
hospitalization of all patients with an altered
level of consciousness, neurologic deficit, or
abnormal CT scan. Compared with the first
alternative, the latter two approaches would
result in approximately a 50% reduction in
costs; however, under these plans a very
small number of patients could still be dis-
charged with a life-threatening compli-
cation.
The safety of discharging patients to the
care of a family member or companion must
also be carefully considered. In a study of
the reliability of at-home observation of pa-
tients with head injury, Cline and Whitley16
concluded that observer compliance signifi-
cantly decreased with increasing patient
age. They suggested that the decision to dis-
charge patients older than 25 years to at-
home observation be carefully considered.
We currently recommend hospital admis-
sion and overnight observation for all pa-
tients with a GCS score of less than 15, pa-
tients with focal neurologic findings or
abnormal mental status, or those with pene-
trating injuries, CSF leaks, or skull fractures.
In addition,, patients in whom mental status
is difficult to assess, e.g., young children,
intoxicated patients, patients without a re-
sponsible observer, a telephone, or ade-
quate transportation, and patients who live
at great distances, are also admitted over-
night.
During observation, the patient should be
assessed hourly. A brief examination that
determines arousability, orientation, pu-
pillary response, and motor functions should
be carried out. Assessment of the level of
consciousness is obviously the most impor-
tant aspect of the examination. We have not
found the frequent determination of vital
signs, which is often used, to add anything to
the neurologic assessment. If the patient re-
mains neurologically intact he or she is dis-
charged the next day when he or she is noted
to be ambulatory and taking an adequate
oral intake.
At the time of discharge the potential for
posttraumatic sequelae is discussed (see
later coverage) and reassurance is given re-
garding possible symptoms. The individual
is cautioned about anticipated difficulties
with mental tasks. Follow-up examination
after mild injury is arranged on a patient-by-
patient basis.
POSTTRAUMATIC SEQUELAE
A variety of sequelae that must be con-
sidered by the physician and discussed with
the patient develop after mild and moder-
ately severe closed head injury. Many such
complications are noted soon after the im-
pact, whereas others occur after various la-
tent intervals.
Intracranial hematoma, perhaps the most
feared complication, has been alluded to in
the section on initial management. Whereas
intracranial hematomas generally present
acutely, the syndrome of delayed traumatic
intracerebral hematoma is occasionally seen
after mild or moderate injury.36, Many of
these lesions represent hemorrhage into
small areas of contusion not seen well ini-
tially. The time from injury to presentation
is generally within 24 to 48 hours. Repeat
CT scanning is essential when delayed neu-
rologic deterioration is observed. Infections
may arise as a result of open fractures, pene-
trating injury, or CSF fistulae, so care should
be taken in excluding these potential com-
plicating factors.14,67
Early seizures, when they are seen in the
context of mild or moderate head injury,
should raise the suspicion of an intracranial
complication. Delayed posttraumatic epi-
lepsy also occurs on occasion in patients
with even mild injuries. A detailed discus-
sion of posttraumatic seizures can be found
in the article by Temkin et a1 in this issue.
Vascular injury in the context of mild or
moderate closed head trauma is a rare but
important clinical entitye6', lo4Frequently,
the carotid arteries are injured, resulting in
dissection or occlusion and subsequent
hemispheric neurologic deficits. Trauma to
the vertebrobasilar system is much less com-
 The Management of Mild an~dModerate Head lnjuries
mon. There may be a delay of hours to days
in the onset of symptoms. Often such a le-
sion is suspected only after the development
of major deficits; however, a high index of
suspicion should b e maintained in the
presence of any focal deficit that develops in
an alert patient or a patient with a history of
minor injury. The presence of a Horner's
syndrome after head injury may implicate a
carotid injury. Urgent cerebral angiography
should be considered in all such cases. Man-
agement must b e individualized but may in-
volve anticoagulation, antiplatelet therapy,
carotid ligation, or bypass surgery.
Cochlear and vestibular dysfunction is
common after mild or moderate head injury
and accounts for a significant fraction of de-
layed or persistent posttraumatic morbidi-
ty.37, 78 Audiologic assessment should be
considered in any patient with persistent
symptoms of vertigo, even in the absence of
subjective tinnitus or hearing loss. Brain
stem auditory-evoked responses may also be
useful in this regard (see later discussion).
Although most cases of vertigo after mild or
moderate head injury are of the benign po-
sitional type, occasionally symptoms are
precipitated by an oval window perilymph
fistula, which may be amenable to surgical
c ~ r r e c t i o nI. n~ ~
other cases, vestibular sup-
pression by pharmocologic agents may be
indicated.
Neuropsychologic Deficits
The growing literature on the behavioral
and neuropsychologic sequelae of mild and
moderate head injury has suggested that sig-
nificant deficits exist for some time after the
injury in many patients.1, 6' 12' 70 The exact
frequency, severity, and duration of these
disturbances is, however, somewhat con-
troversial. A wide range of deficits have
been documented after mild to moderate
head injury, including difficulty with short-
term and perhaps long-term memory, de-
creases in the rate of information proces-
sing, slowed reaction times, problems with
verbal skills, and difficulty with perceptual
tasks.'% 3 4 , 5 6 5 7
Several reports from the University of
Virginia have suggested that neurobehav-
449
ioral deficits may be found in as many as
two thirds of patients with mild or mod-
erate head injury examined 3 months after
injury.6,83'84The fact that two thirds of these
patients with moderate injury and 34% of
those with mild brain injury were unem-
ployed 3 months after injury was taken to
imply a functional significance to the neuro-
psychologic findings. These studies were
criticized, however, for not providing appro-
priate control groups or adequate control-
ling for premorbid difficulties such as alco-
holism or psychiatric disorders.
The studies of Gronwall and W r i g h t ~ o n ~ ~ .
34 have also documented significant deficits
particularly with respect to attention, con-
centration, and information processing abil-
ity and have shown correlation of these def-
icits with the duration of PTA. These
authors, however, have documented a re-
covery in most cases within 4 to 6 weeks
after minor injury.34 In an interesting further
study, however, impairment of recent mem-
ory and attention was carried out under con-
ditions of mild hypoxic stress.22Gentilini et
al3' have also documented neuropsycho-
logic recovery within 1month after injury.
O'Shaughnessy et a173studied 39 patients
with slightly more severe injuries and found
neuropsychologic deficits persisting in up to
46% of patients 6 months after injury. They
also observed a significant decrease in em-
ployment at 6 months in this small series of
patients. Duration of PTA was not found to
be helpful in predicting severity or duration
of deficits or return to work. Other studies
have also found a poor correlation between
length of PTA and neuropsychologic impair-
ment.6
Recently in a multicenter study by Levin
et neuropsychologic examinations at 1
week, 1 month, and 3 months after minor
head injury demonstrated resolution of def-
icits in memory, attention, and information
processing speed over a 3-month time
course. Thus, although some patients may
demonstrate long-lasting difficulties, most
individuals exhibit n e ~ r o p s ~ c h o l o g idefi-
c
cits that although real, are relatively short-
lived.
As pointed out by Levin et however,
the transient nature of these objective
neuropsychologic deficits by no means
450 Dennis G . Vollmer and Ralph G . Dacey, Jr.
mitigates against the potential for axonal
shearing as a basis for these deficits. The
experimental studies of Povlishock and oth-
ers, as well as the clinical report by Oppen-
heimer provides strong mo hologic sup-
port for this hypothesis.39~715 s' It is
793
certainly conceivable that the redundancy of
neural connections as well as the potential
for plasticity in the nervous system provide a
basis for functional recovery, albeit with
some reduction in functional reserve. Such a
mechanism might account for the cumu-
lative nature of multiple minor injuries.35
Various approaches to the neuropsycho-
logic assessment of patients with head inju-
ries have been taken, using different bat-
teries of tests to assess a large number of
neuropsychologic functions. The rationale
behind the various testing modalities is be-
yond the scope of this discussion; interested
readers are referred to the reviews by Ruff et
alF1 Lezak?' and Boll.13This kind of evalu-
ation is highly sensitive and, as noted ear-
lier, may be abnormal even in patients with
minor injuries who have no deficits on
clinical examination. Unfortunately, such
testing is both time-consuming and expen-
sive. A difficulty in interpreting test results
from an individual patient arises because of
the lack of preinjury data. It is our opinion
that such testing adds little to the early man-
agement of the patient with minor or moder-
ate head injuries; however, unexplained
prolonged symptoms may occasionally be
better understood when the results of neuro-
psychologic testing are examined.
Brain Stem Auditory-Evoked Responses
Brain stem auditory evoked responses
(BAERs) have recently been found to be ab-
normal following mild closed head injury in
a small number of patient series.''? 72' 7
" tients is shown in Table 7. A striking consis-
92394 The proportion of patients demonstrat-
ing abnormalities has varied from 0% to
44%, probably reflecting differences in pa-
tient selection, the various groups studied,
as well as timing of the testing.
A preliminary study by Ruth et alg2dem-
onstrated that 45% of 66 patients tested with
minor injuries had responses more than two
standard deviations from the mean of a nor-
mal control group, and 19%had results more
than three standard deviations away. When
abnormalities on BAERs were examined in
relation to the presence or absence of
postconcussional symptoms, however, no
correlation was found. BAER abnormali-
ties were as frequent in patients without
symptoms as in those with symptoms.
A more recent, large study by Schoen-
huber et alg5 examined 103 patients within
48 hours of a mild head injury. Pathologic
BAERs were found in approximately 7%,
but again no significant correlation was
found with postconcussional symptoms.
These studies therefore seem to confirm a
disturbance of brain stem function in some
patients after minor head injury, but do not
support the notion that this physiologic ab-
normality is the source of postconcussional
symptoms.
Postconcussion Syndrome
Immediately after minor or moderate
head injury, most patients report a variety of
symptoms including headache, dizziness,
vertigo, irritability, difficulty with concen-
tration, memory deficits, and easy fatiga-
bility. Frequently, these symptoms are seen
in the absence of objective findings on neu-
rologic examination. Although many of
these symptoms may preclude a return to
normal activity, they are generally short-
lived and resolve spontaneously. In a small
percentage of patients, however, such
symptoms persist and thus characterize the
postconcussion syndrome or posttraumatic
syndrome. In other patients, late occurrence
of irritability, depression, or anxiety may be
observed with associated functional diffi-
culties.
The relative incidence of the various post-
traumatic symptoms for three series of pa-
tency in the types of symptoms described
from patient to patient can be observed.
Equally striking, however, is the variability
in both the degree and duration of
symptoms. Lidvall et a15' examined the time
course of postconcussional symptoms in 83
patients. Thev noted a marked decrease in
the percentagk of patients experiencing one
or more postconcussional symptoms over
time, decreasing from 73% at 2 days to 24% 3
 T h e Management of Mild and Moderate Head Injuries 451
Table 7. Relative Incidence o f Posttraumatic Complaints
RUTHERFORD LIDVALL KESHAVAN
E T AL'~ ET AL~' ET AL~' TOTAL

Follow-up Period 6 weeks 0-3 months 3 months

Total Patients 145 83 60
Percentage Showing
Headache 25 47
Dizziness 15 30
Fatigue 9 37
Anxiety 19 28
Insomnia 15 37
Insensitivity to noise NK 30
Difficulty with concentration 8 8
Irritability 9 17
Subjective memory impairment 8 8
Depression 6 NK
Any of above 51 65
Abbreviation: NK = not known.
From Lishman W A : Physiogenesis and psychogenesi s in the post-concussional syndrome. Br J Psychiatry 153:
460, 1988; with permission.

months after the trauma. Different time been associated with initial deficits affecting
courses were observed, however, for differ- the special senses.46, 933

ent symptoms. For example, the percent re-
porting headaches generally declined over
time, whereas anxiety and irritability tended
to increase between the first and second
weeks after injury. Lidvall et alS9 were also
-
able to examine the clustering: of the various
posttraumatic symptoms as a function of
time and noted a gradual evolution in the
symptom complex. Soon after injury, head-
ache was frequently associated with diz-
ziness and difficulty with concentration.
Later on, anxiety and depression were more
often seen in connection with headache.
The etiologic basis for postconcussional
symptoms has long been debated in the
medical literature.46, 48, 60, 66, 93, 973 103 Or-
ganic and psychologic factors are most often
invoked, although the role of compensation
and other social and environmental influ-
ences cannot be totallv dismissed.
Some symptoms such as dizziness, diplo-
pia, and hyperacusis may be explained by
injury to vestibular and brain stem struc-
tures. This possibility is supported by the
findings on neuro-otologic examination and
BAER testing (see earlier discussion). Sub-
jective memory impairment and difficulty
with concentration and fatigue may corre-
late with neuropathologic evidence for axo-
na1 injury.39, 79, 80 It is noteworthy that
757
persistent postconcussional symptoms such
as anosmia, diplopia, and hearing loss have
It should be emphasized, however, that
although these associations between
postconcussional symptoms and objective
evidence of brain damage support a causal
relationship, a direct relationship has not
been conclusively demonstrated, e.g., the
finding of neuropsychologic deficits in pa-
tients without postconcussional symptoms
and their absence in patients with symptom-
atology would argue against a direct cause
and effect relationship.
The role of psychogenic factors in the de-
velopment and persistence of postcon-
cussional symptoms remains uncertain, al-
though as pointed out by Alves and Jane,'
the fundamental issue is not whether a par-
ticular symptom has a psychogenic or or-
ganic basis, but whether or not the symptom
is reversible. It would seem probable that
in many instances, the postconcussional
symptoms begin on an organic basis, but
over time, especially in persistent cases, the
relative importance of psychogenic factors
increases.(jO The complexities involved in
the genesis of posttraumatic symptoms may
preclude an accurate differentiation of these
various putative causes in the individual pa-
tient.
T h e role of rehabilitation efforts for the
patient with mild head injuries remains un-
certain. certainly few coordinated efforts to
examine the impact of interventions in this
452 Dennis G. Vollmer an~dRalph G. Dacey, Jr.
group of patients have been undertaken.
GronwalP2 has identified four important el-
ements in the rehabilitation of minor head
injuries: (1) reassurance, (2) education, (3)
support, and (4) regular monitoring of pro-
gress. Further study is required to define
optimal means of carrying out these ele-
ments.
SUMMARY
The majority of patients seeking medical
care after head trauma have sustained inju-
ries of mild or moderate severity, i.e., GCS
scores of 13 to 15 or 9 to 12, respectively.
Mortality rates under these circumstances
are generally low; however, serious compli-
cations must be detected and treated early.
The initial evaluation involves determina-
tion of level of consciousness and examina-
tion for the presence of focal neurologic def-
icits. Skull radiography has a limited role in
the management of mild and moderate head
injuries, but consideration must be given to
local factors such as the availability of cra-
nial CT. CT scanning is a safe, noninva-
sive, and generally cost-effective means of
assessing patients at risk for developing in-
tracranial complications. The role of MR im-
aging in evaluating minor head injuries is
not yet established.
Patients with an altered level of con-
sciousness require hospitalization in essen-
tially all cases. Selected patients with a GCS
score of 15 also benefit from overnight hos-
pitalization and observation.
After mild and moderate head injury, sig-
nificant neuropsychologic deficits are fre-
quent, but are generally finite in their dura-
tion. Postconcussive symptoms are also
generally self-limited. Although objective
evidence suggests that structural brain dam-
age results from mild injuries, the relation-
ship between postconcussional symptoms
and structural damage is unclear.
Persistent postconcussional symptomatol-
ogy probably arises from a combination of
physiogenic and psychogenic causes. It is
possible that early patient education and
reassurance will reduce the incidence of
prolonged postconcussional symptomatol-
om.
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Department of Neurosurgery
Washington University School of Medicine
660 South Euclid, Box 8057
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