Analysis of management in thirty-three closed head injury patients who "talked and deteriorated"

Of 215 patients with severe head injuries, 33 (15%) closed head injury patients who talked before their conditions deteriorated to a Glasgow coma scale score of 8 or less were identified. Of this select group, 15 died (45%), but none of the remaining were left in a vegetative state and 14 patients had a "favorable" outcome (42%). Twenty-five patients (76%) underwent surgical decompression. In these 25 patients, 14 subdural hematomas, 4 epidural hematomas, and 7 intracerebral contusions and hematomas were the initial surgical lesions. Twenty of the 25 patients were operated on within 4 hours (16 within 2 hours) of their neurological deterioration. Eleven of the 25 surgically treated died, for a mortality rate of 44%. All 15 deaths were studied further. Autopsies with examination of the brain were performed in 13 patients. Five patients died with severe brain injuries not complicated by iatrogenic factors, and 4 patients died of severe associated injuries. Iatrogenic factors significantly complicated the deaths of 6 patients (40%). It is concluded that most patients who "talk and deteriorate" have sustained very serious life-threatening injuries. Intracranial hematomas are the most frequent cause of this situation, and rapid diagnosis and decompression is the most important factor in salvaging these patients.