1) A 7-year-old male child presented with a severe head injury after falling 4 stories, with an initial normal CT scan but gradually rising intracranial pressure. 2) The patient underwent an emergency decompressive craniectomy due to refractory elevated ICP, which improved his condition and he was successfully extubated on the third postoperative day. 3) An audit of over 2000 head injury patients at this trauma center over 18 months found that 53% had severe injuries, with an overall mortality of 22%, rising to 36% for severe injuries.

1. Deepak Agrawal Dept of Neurosurgery, JPN Apex Trauma Centre MANAGEMENT OF SEVERE HEAD INJURY WITH ‘NORMAL’ CT HEAD

3. NCCT head at admission

10. Post-operative scans

11. Post-operative scans

16. OBSERVATIONS (AGE GROUP INCIDENCE) PEDIATRIC (< 12 YR)= 328 ( 15 %) ELDERLY (>60 YRS)= 181 ( 8 %)

17. OBSERVATIONS (INCIDENCE OF VARIOUS H.I. GROUPS) MINOR HI -29% MOD. HI -18% SEVERE HI -53%

18. OBSERVATIONS SEVERE HEAD INJURY

19. OUTCOME (MORTALITY) GROUP NO. OF IN-HOSPITAL MORTALITY TOTAL CASES % Overall 454 2068 22 Minor HI 14 598 2 Moderate HI 45 380 12 Severe HI 395 1090 36

20. OUTCOME ( MORTALITY AS PER AGE GROUP) GROUP NO. OF MORTALITY TOTAL CASES % Children (< 12 yrs) 118 305 38 Adult ( 20-50 yrs) 191 1118 17 Elderly ( 50-80 yrs) 126 339 37

21. OUTCOME (GOS ) OVERALL DEATH - 454 / 2068 (22%) Glasgow Outcome Score (Following Severe Head Injury) %age 1 Death 36% 2 Vegetative 18% 3 Severe disabled 12% 4 Mod. disabled 16% 5 Good recovery 18%

22. OUTCOME (SURGERY vs CONSERVATIVE ) MODE OF TREATMENT ADMISSON GCS SCORE SURVIVED DIED P VALUE SEVERE HEAD INJURY SURGERY 3-8 617 192 <0.05 CONSERVATIVE 3-8 78 203 MODERATE HEAD INJURY SURGERY 9-12 109 18 CONSERVATIVE 9-12 226 27 MINOR HEAD INJURY SURGERY 13-15 23 2 CONSERVATIVE 13-15 561 12

23. COMPARISON WITH WORLD LITERATURE Author MORTALITY OVERALL MINOR MODERATE SEVERE Kagan RJ 1994 26.7% - - 41.4% Fakhry SM 2004 28.8% - - - Udekwu P 2004 21% - - 31.5% AIIMS 2009 22% 2% 12% 36%

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