Keywords
contusion index - Glasgow Coma Scale - head injury - intracerebral contusions
Introduction
Head injury is one of the leading causes of morbidity and mortality. The current reported
mortality of traumatic brain injury is 40 per 100,000 annually.[1] Head injury might result in extradural hematoma, subdural hematoma, subarachnoid
hemorrhage, and intracerebral hematoma. Intracerebral hematoma is also called contusion.
The vascularity of gray matter is more than white matter. Contusion primarily occur
in superficial gray matter with secondary extension to deep white matter.[2]
[3]
[4]
[5] Contusions can be unilateral or bilateral ranging from small petechial to large
hematoma. Contusions are more common in frontal and temporal lobes because of interface
with underlying bony projections.[6] They are rarely seen in occipital and parietal lobes. Contusion results from coup
or contrecoup impact to the head with differential movement of brain within the skull
and results in sliding of cortex along the inner rough surface of the skull.[7]
[8]
[9]
[10] It is sometimes difficult for neurosurgeons to decide whether to perform conservative
or surgical intervention, so a standard tool of measurement is required along with
Glasgow Coma Scale (GCS) for more favorable results of a particular treatment. It
has been mentioned to a limited level in international literature and no national
and international studies have been done on contusion index. So the study will provide
a guideline for practicing neurosurgeons. [Table 1] and [Figs. 1] and 2 give some idea of how we calculated contusion index.
Table 1
Contusion index[5]
|
Grade
|
Depth of contusion
|
Extent of contusion
|
|
Note: Contusion index is calculated as:
Depth of contusion × Extent of contusion = Contusion index score (0–9).
|
|
0
|
Absent
|
Absent
|
|
1
|
Affects half of the cortex of brain
|
Localized
|
|
2
|
Affects full thickness of cortex
|
Moderately extensive
|
|
3
|
Extension to white matter
|
Extensive
|
Fig. 1 Computed tomography (CT) brain with right frontal contusion with contusion index = 3 × 3 = 9.
Methodology
This descriptive study was conducted in the Department of Neurosurgery, Lady Reading
Hospital, Peshawar, Pakistan from January 2017 to December 2018. Patients were assessed
by history, neurological, and systemic examination for associated injuries and computed
tomography (CT) brain. Total number of patients with traumatic intracerebral contusions
included in this study was 60 with age ranges from 5 to 75 years. Both male and female
were included in the study. Patients with other coexisting traumatic intracranial
hematomas like extradural hematoma, subdural hematoma, intraventricular hemorrhage,
and polytrauma were excluded from this study. Contusion index of patients was calculated
by noncontrast-enhanced CT brain. On arrival patient GCS was documented. The management
protocol, that is, conservative or surgical, was provided to individual patient according
to contusion index as calculated. Outcome of management was assessed in terms of improvement
in GCS. Patients with contusion index of 0 to 4 were treated conservatively. Patients
with contusion index of 6 were treated surgically, and patients with contusion index
of 9 were treated conservatively/surgically depending upon GCS. Some of the cases
of contusions where we applied contusion index are shown in Figs. 1 and 2.
Results
A total of 60 patients were diagnosed by CT brain as traumatic contusions. Out of
these patients 3 patients had GCS of 15/15) and contusion index of 1. Twelve patients
had GCS of 14/15 and contusion index of 2 and 7 patients had GCS 13/15 and contusion
index 3. All these patients with contusions index 1 to 3 were treated conservatively.
Patients were given intravenous steroids, antiepileptics, intravenous fluids, and
painkillers. On the third day of admission, all of the patients had GCS of 15/15 with
slight hypodensity around contusions on serial CT brain. It shows that these patients
had excellent recovery. Similarly, 14 patients had GCS of 11/15 and contusion index
of 4. These patients were operated and hematoma was evacuated with postoperative GCS
of 15/15 in 11 patients and GCS of 13/15 in 3 patients, respectively, on the third
postoperative day. So they had good recovery. In our study, 15 patients had GCS of
9/15 and contusion index of 6. Patients were operated and evacuation of hematoma was
done with postoperative GCS of 12/15 on the third postoperative day in 13 patients.
Two patients did not recover and died in intensive care unit (ICU). So these patients
had satisfactory outcome. The last group of 9 patients had GCS less than 8 and contusion
index of 9. Out of these 9 patients, 5 were operated and 4 were managed conservatively
in the ICU but all the patients died, so these patients had poor outcome. See [Tables 2]
[]–[4] for details. [Table 5] is for Glasgow Outcome Scale extended score.
Table 2
Conservatively treated patients
|
No of patients
|
Contusion index
|
GCS at day 1
|
GCS at day 3
|
Outcome
|
|
Abbreviation: GCS, Glasgow Coma Scale.
|
|
5
|
9 (Operated)
|
7/15
|
5/15
|
Died
|
|
4
|
9 (No surgery)
|
5/15
|
3/15
|
Died
|
Table 3
Conservative/surgically treated patients
|
No of patients
|
Contusion index
|
GCS at day 1
|
GCS at day 3
|
Outcome
|
|
Abbreviation: GCS, Glasgow Coma Scale.
|
|
14
|
4
|
11/15
|
15/15
|
Good recovery
|
|
15
|
6
|
9/15
|
12/15
|
Delayed recovery
|
Table 4
Surgically treated patients
|
No of patients
|
Contusion index
|
GCS at day 1
|
GCS at day 3
|
Outcome
|
|
Abbreviation: GCS, Glasgow Coma Scale.
|
|
3/60
|
1
|
15/15
|
15/15
|
Full recovery
|
|
12/60
|
2
|
14/15
|
15/15
|
Full recovery
|
|
7/60
|
3
|
13/15
|
13/15
|
Delayed recovery
|
Table 5
GOSE score
|
GOSE
|
Category
|
Frequency at 6 mo (no of patients)
|
|
Abbreviation: GOSE, Glasgow Outcome Scale extended.
|
|
1
|
Death
|
9
|
|
2
|
Vegetative state
|
0
|
|
3
|
Severe disability lower
|
0
|
|
4
|
Severe disability upper
|
2
|
|
5
|
Moderate disability lower
|
7
|
|
6
|
Moderate disability upper
|
15
|
|
7
|
Good recovery lower
|
12
|
|
8
|
Good recovery upper
|
15
|
Discussion
In this study, we found that for patients with contusion index of 1 to 3 conservative
management was good enough. It was noted that all these patients had GCS above 10/15.These
patients survived and had excellent recovery with nonoperative treatment. Since there
are no international studies available, therefore only one national study done on
contusion index has same results as mentioned in our study.[11] Much larger studies are therefore necessary to take into account the different aspects
of our study before a definitive management protocol can be laid down on the basis
of contusion index.
Similarly, group 2 of our study included 29 patients with contusion index of 4 to
6. All of these patients had GCS more than 8 and were operated. Patients were subjected
to craniotomy with evacuation of hematoma and water tight closure of dura. Postoperatively,
patients were kept in ICU with regular observation of vitals and GCS. All of these
patients survived and had good recovery. So the above results again favor the initial
surgical management in patients with contusion index of 4 to 6. Again, this is all
an observation from our study and as this is a descriptive study and we do not have
any previous studies relating contusion index to GCS on the basis of surgical versus
conservative management, we cannot compare our results with any other studies.
The third group of patients had contusion index of 9. Of the 9 patients in the group,
5 had a good GCS (7/15) so they were operated with the hope to give them a chance
for survival. But all these patients were on ventilators for many days in ICU and
died later. Similarly, 4 patients with contusion index 9 were treated conservatively
in the ICU. They had GCS of 5/15 on presentation. They keep on deteriorating in spite
of best possible conservative treatment and died later on. This was in accordance
with one local study done on contusion index showing same results.[12]
[13] Our study design was descriptive and since no such work has been done in the past
to determine any relationship between contusion index and GCS on the basis of conservative
or surgical management we cannot give a definitive management protocol. We have simply
stated what our results revealed. This study has, in no doubt, provided a framework
for further studies in this context and is also free for criticism on how it could
have been improved. The main purpose is to provide a framework for future studies
for patients with contusions based on contusion index. This is very important because
this will help the on-call neurosurgeon to arrive at a decision regarding conservative
versus surgical management of patients with cerebral contusions based on contusion
index and will also help to avoid unnecessary surgeries or vice versa.
There are many prognostic factors associated with outcomes after traumatic brain injury
like GCS on admission, motor score, mid-line shift on CT scan, pupil response, subdural
hematoma, gender, and intraventricular hemorrhage. We evaluated the outcome in the
basis of contusion index for all patients.
Conclusion
In our conclusion we can say that patients with contusion index of 1 to 3 should be
conservatively managed. Patients with contusion index of 4 to 6 should be operated.
Patients with contusion index of 9, no matter what, always showed a poor outcome.
In our study there was 100% mortality in this group.
Fig. 2 Contusion index is 2.5 × 3.0 = 7.5.
