mild head injury: a misnomer
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BRAIN INJURY, 1999, VOL. 13, NO. 7, 463 ± 475
Mild head injury: a misnomer
A N D R EÂ E T E L L I E R ² ,
L O R I C . D E L L A M A L V A ¶ ,
A D A M C W I N N ³ , S T E V E G R A H O V A C § ,
W . M O R R I S H § a n d
M A U R E E N B R E N N A N - B A R N E S ³
² Department of Psychology (Neuropsychology Service); ³ Trauma Services;
§Department of Radiology, Ottawa Hospital, University of Ottawa, Ontario,
Canada; ¶ Psychology Service, The Rehabilitation Centre, Ottawa, Ontario, Canada
(Received 21 January 1999; accepted 20 February 1999 )
Despite controversy surrounding the concept of mild head injury (MHI), it is becoming evident that
even a head trauma termed `mild’ may result in significant behavioural sequelae. The present study was
an attempt at documenting structural cerebral damage, by way of computerized tomography, in a
group of patients having suffered a MHI as defined by the Glasgow Coma Scale (GCS) score. A 1-year
retrospective chart review identified 80 MHI patients who presented to the Emergency department of
a lead hospital for trauma. Sixty-six per cent of these MHI patients were scanned. Evidence of
intracranial abnormalities was obtained in 31% of the overall sample. Patients with a lower GCS
score had a higher percentage of abnormal scans than those with a GCS score of either 14 or 15.
The present findings suggest that a MHI can be associated with significant morbidity, and that a MHI
group does not constitute a homogeneous pool of patients.
Introduction
Mild head injury (MHI) is a major public health concern, given the large number of
patients affected each year and the morbidity associated with this condition. It is
estimated that approximately 800 000 people in the US alone suffer a MHI each
year [1], this group constituting as high as 80% of all head-injured patients and
representing the majority of head-injured patients seen in the emergency depart-
ment [2± 5]. It is not surprising, given these figures, that MHI has been termed the
s̀ilent epidemic’ of our times [6].
The neuropsychological and physical sequelae of a traumatic brain injury, par-
ticularly when the injury is moderate or severe, have been well documented.
Unfortunately, for the patient suffering from a milder form of injury, the possible
sequelae are subtle and more difficult to assess, and can occur in the absence of
obvious structural damage to the brain. This may explain why most of the original
work done in the area of MHI gave rise to such a concept as accident or compensa-
tion neurosis [7, 8]. Over time, the documentation of deficits by way of objective
Brain Injury ISSN 0269± 9052 print/ISSN 1362± 301X online Ñ 1999 Taylor & Francis Ltd
http://www.tandf.co.uk/JNLS/bin.htm
http://www.taylorandfrancis.com/JNLS/bin.htm
Correspondence to: A. Tellier, Neuropsychology, Module Q, Ottawa Hospital, General Campus,
501 Smyth Road, Ottawa, Ontario, Canada K1H 8L6. e-mail: Atellier@ogh.on.ca
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neuropsychological testing, as well as patients’ reports of cognitive deficits in the
absence of obvious secondary gains, have given credibility to the symptoms voiced
by MHI patients [9± 11].
There is mounting evidence that MHI can result in significant morbidity [12].
Up to 8% of MHI patients can suffer from focal neurological deficits, increased
intracranial pressure, and life-threatening haematomas, and 3± 5% may require
neurosurgical intervention [12± 16]. In one series, 15 ± 20% of patients who obtained
a perfect GCS score went on to develop a surgically significant acute traumatic
intracranial haematoma [17]. Seizures, cranial nerve deficits, visual dysfunction,
audiovestibular sequelae, fatigue, sleep disturbances, migraines, dizziness, and bal-
ance dysfunction have also been reported in some MHI cases [12, 18 ± 22]. From a
neuropathological point of view, brief concussion has been associated with struc-
tural damage [23] and the contribution of biochemical and physiological changes to
the pathogenesis of MHI-related cognitive difficulties (in the absence of discernable
structural changes) has been documented [24]. The animal literature also contains
reports of axonal disruption and degeneration as consistent features of MHI in the
absence of actual physical shearing or tearing or of any observable behavioural
sequelae [25, 26].
From a neuropsychological point of view, a vast amount of literature has docu-
mented sequelae in MHI patients. More specifically, reduced information pro-
cessing capacity, impaired concentration, memory impairment, transient global
amnesia, faulty judgement, and visuospatial deficits have been reported [9, 11, 19,
21, 27± 32]. Although many have limited their cognitive assessment of mild TBI
patients to very early on in the recovery process [33], some of the neuro-
psychological deficits associated with a MHI have been documented as late as
2 years post-trauma [11]. Mood changes in the form of depression have also been
reported [18].
Despite strong evidence regarding the presence of significant sequelae in MHI
cases, many professionals continue to equate long-lasting deficits in the MHI patient
with malingering, based on the notion that such injury should not result in any
permanent sequelae. For instance, at a previous meeting of the International
Neuropsychological Society, the concept of malingering was largely discussed in
the context of MHI [59]. This, unfortunately, promotes the unwarranted notion
that a large number of MHI patients are exaggerating their symptoms. While such
cases undoubtedly exist, it would be unwise to deny the large number of MHI
patients proper management because of a few isolated cases of malingering. As
health care providers, our ability to accurately recognize that important sequelae
may surface following what appears to be a relatively benign neurological condition
has important clinical and legal repercussions. Failure to recognize the presence of
legitimate neurological and/or neuropsychological complications would be a dis-
service to the patient in need of care.
It is the belief of this team of investigators that the qualifier `mild’ may be
misleading, in that a MHI can be associated with significant structural and
behavioural sequelae. The present study was an attempt at investigating actual
structural cerebral damage, by way of CT scanning, in a group of patients
having suffered a head trauma termed `mild’ as defined by the Glasgow Coma
Scale (GCS) score [34], a commonly used index of severity and neurologic
dysfunction.
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Methods
Subjects
Eighty MHI patients were retrospectively identified from the trauma registry of an
acute care hospital and lead centre for trauma over a 1-year period. A MHI was
defined on the basis of a GCS score of 13± 15 upon arrival to hospital and during
their initial period of observation [34]. This definition is in agreement with previous
research, although investigators have differed with respect to the additional clinical
features that they consider [12, 35± 38]. Only patients who were taken to hospital on
the day of the head trauma, or else came in with clear documentation of their initial
GCS score, were included in this study in order to ensure that more severely head-
injured patients whose level of consciousness may have improved in the interim did
not end up being classified as `mildly’ impaired. In all cases, the GCS score was
assigned by the nursing staff of the Emergency department. In keeping with pre-
vious figures, the sample was largely male (80%). The mean age of the sample was
31.60 years (SD 12.08). Fifty-three patients (66% of the original sample) were sent
for CT scanning. Of those scanned, 54% sustained their MHI as a result of a motor
vehicle accident, 23% received blows to the head, 17% sustained falls, and 6% were
struck by cars (two pedestrians, one cyclist). The demographic data and breakdown
of GCS scores for the overall sample and scanned subsample can be found in table 1.
Measures
The CT scans were obtained on a GE CT 9800 scanner. All scans were unenhanced
and obtained on the day of injury, with two exceptions: one patient was scanned 2
days post-trauma while another was scanned 6 days following the initial head injury.
All CT scans were ordered by Emergency physicians. The decision to order CT
scans on Emergency patients was based on the usual practice of Emergency physi-
cians in the clinical evaluation of patients. All CT scans were initially read by the
neuroradiologist on call. In addition, for the purpose of this study, readings were
independently obtained from two neuroradiologists who were blind to the clinical
Mild head injury 465
Table 1. Demographic data (% of patients)
Demographic data
Overall sample
(%) (n = 80)
Scanned sample
(%) (n = 53)
Sex
Male 80.0 83.0
Female 20.0 17.0
Glasgow Coma Scale
13 13.8 17.0
14 22.5 28.3
15 63.7 54.7
Age (years)
< 20 11.2 3.8
20± 29 41.3 41.5
30± 39 22.5 24.5
40± 49 11.2 13.2
50± 59 13.8 17.0
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status of the participants (they were given a mixture of 57 scans of MHI individuals
and 33 scans of normal controls with age and sex as sole identifying data).
Results
There was 100% agreement between the two neuroradiologists in the rating of all
normal control scans. As far as the clinical sample was concerned, there was a
significant degree of agreement between either neuroradiologist and the initial
clinical readings (rs = 0.66± 0.68, p < 0.000) as well as between the two neuro-
radiologists (rs = 0.79, p < 0.000).
Of the 66% of MHI patients who were sent for CT scanning, 25 patients (i.e.
31% of the entire study group) had evidence of intracranial abnormalities on CT
scan. The different types of findings are summarized in table 2. Some illustrative
examples of CT scan abnormalities are found in figures 1± 5. All other patients who
underwent scanning had either negative scans or evidence of extracranial abnorm-
alities only.
An inverse relationship was documented between GCS score and the number of
requested scans, indicating that the decision to request a scan was largely prompted
by clinical presentation: 82% of those with a GCS score of 13 and 83% of those with
a GCS score of 14 versus only 57% of those with a GCS score of 15 were sent for
CT scanning. A breakdown of intracranial abnormalities by GCS score is found in
table 3. Of scanned patients, those with the lowest GCS score were more likely to
have positive findings on CT scanning (89%).
The scanned sample also differed significantly from the unscanned group in
terms of alcohol consumption on the day of injury, with 34% of the scanned
group said to have been drinking versus only 4% of the non-scanned group
(Z = 2.99, p < 0.003). With respect to age, group differences were short of
significance (t(78) = 2.27, p < 0.03) although the scanned group was slightly
older (33.77, SD 12.20) than the non-scanned group (27.48, SD 10.74).
466 A. Tellier et al.
Table 2. Computerized tomography scan abnormalities
CT findings Number of occurrences ²
Cerebral contusions 12
Cerebral oedema 4
Intracerebral haemorrhage 3
Intraventricular haemorrhage 3
Subarachnoid haemorrhage 5
Subdural haematoma 2
Epidural haematoma ³ 3
Midline shift 3
Pneumocephalus 3
² Total number of abnormalities (38) exceeds the actual number of patients
who had abnormal scans (n = 25) as many patients had more than one
structural abnormality.
³ All required evacuation.
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D iscuss ion
Given that many MHI patients do not seek medical attention and that an even
larger percentage of these patients generally do not get admitted to hospital, the
present sample represents a biased group of MHI patients. Nevertheless, by virtue of
the fact that all patients were assigned a GCS of 13± 15 at the time of intake, they do
represent a group of patients that would be considered mildly injured on the basis of
Mild head injury 467
Figure 1. Cerebral contusions in a 46 year-old man who fell and struck his occiput while walking; no loss of
consciousness; symptoms (24 hour post-fall) consisted of severe headache and vomiting; Glasgow Coma Scale
score = 15.
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468 A. Tellier et al.
Fig
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a widely used classification scheme. Other limitations of the study consist of the lack
of neuroradiological data on the 27 patients who did not have a CT scan and the
retrospective nature of this review.
Surprisingly, even in cases of `mild’ head trauma, 31% of patients (based on the
overall sample) had evidence of intracranial abnormalities. It should be noted that
none of the patients with positive scans were on anticoagulant therapy at the time of
their injury. This subgroup of patients with positive CT scan findings has previously
been labelled the complicated MHI group [38]. The finding of a considerable number
of cases with intracranial abnormalities is in agreement with previous reports of CT
scan findings in admitted patients with a MHI [39, 40]. One might hypothesize,
given the greater sensitivity of MRI and SPECT to the detection of certain types of
MHI-related lesions [41± 50] that a great number of intracranial abnormalities would
have been identified had these tests been readily available in the institution. The
degree to which MRI and SPECT findings translate into clinically significant
Mild head injury 469
Figure 3. Cerebral contusions and cerebral oedema in a 49 year-old man struck on the left temple with ball (he
drove himself to hospital, complaining of intense headaches); no loss of consciousness; Glasgow Coma Scale
score = 13± 14.
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abnormalities remains, however, a matter of debate [43 ± 45, 48, 51] that extends
beyond the scope of this paper.
The results demonstrate that the MHI group does not constitute a homogeneous
pool of patients, not only in terms of intracranial abnormalities in the group as a
whole, but also with respect to the greater likelihood of finding abnormalities in
patients with a GCS score of 13. The significant heterogeneity afforded by the use
470 A. Tellier et al.
Figure 4. Intraparenchymal haematoma, subfacial herniation, and oedema in a 17 year-old man who fell while
playing basketball (an angiogram was negative for aneurysm or arteriovenous malformation); loss of con-
sciousness less than 1 minute; Glasgow Coma Scale score = 13.
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of GCS scores of 13± 15 in terms of neuroradiological abnormalities, neurosurgical
interventions, and length of stay and the need to recognize those with a score of 15
as distinct from those with lower scores have received considerable press of late [52 ±
54]. The findings document the presence of an inverse relationship between GCS
score and the likelihood that structural cerebral damage can occur. In clinical
practice, there exists the potential bias in CT referral in favour of those with the
lowest GCS score, because of the confounding presence of alcohol intoxication.
Indeed, evidence was found of a significantly greater proportion of intoxicated
patients in the scanned group. However, there were more intoxicated individuals
with a GCS of 15 (n = 10) who were sent for neuroimaging than there were with a
GCS of 13 (n = 5), suggesting that, although alcohol status may create a confound-
ing bias, other clinical parameters are used in the determination of who is sent for
CT scanning. In fact, the finding that actual brain damage was documented in 89%
of the more s̀evere’ MHI patients referred for CT scanning suggests that the
decision to refer these patients was prompted by the accurate suspicion of actual
brain damage.
From a neuropsychological point of view, it is interesting to note that despite
evidence of actual brain damage in as many as 31% of all of the admitted MHI
patients, only 3% of MHI patients were referred for neuropsychological investiga-
tion, the majority of inpatient referrals consisting of more severe cases of traumatic
Mild head injury 471
Figure 5(a)
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brain injury. Such a low rate of neuropsychological referrals raises two issues. On
the one hand, it may reflect an assumption of minimal, if any, cerebral dysfunction
on the part of referring sources. Alternatively, it may be that there exist no stan-
dardized criteria to assist physicians in determining the appropriateness of a neuro-
psychology referral for MHI patients. In fact, the lack of a simple technique to
472 A. Tellier et al.
Figure 5. Cerebral contusion (a) and subarachnoid haemorrhage (b) in a 57 year-old man who fell off a bridge
(work-related); loss of consciousness of 4± 5 minutes; Glasgow Coma Scale score = 15.
Table 3. Computerized tomography scan abnormalities by Glasgow Coma Scale scores
Glasgow Coma Scale scores
CT findings 13 (n = 9) ² 14 (n = 15) 15 (n = 29)
Cerebral contusions 1 (8.3%) 2 (50%) 9 (41.0%)
Cerebral oedema 1 (8.3%) 3 (13.6%)
Intracerebral haemorrhage 2 (16.7%) 1 (4.5%)
Intraventricular haemorrhage 3 (25.0%)
Subarachnoid haemorrhage 2 (16.7%) 3 (13.6%)
Subdural haematoma 2 (9.1%)
Epidural haematoma 1 (25%) 2 (9.1%)
Midline shift 2 (16.7%) 1 (25%)
Pneumocephalus 1 (8.3%) 2 (9.1%)
Total number of CT scan abnormalities ³ 12 4 22
Percentage of abnormal scans/total scans 89% 27% 45%
² n = Number of patients scanned.
³ Total number of abnormalities exceeds the actual number of patients who had abnormal scans, as many patients
had more than one structural abnormality.
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detect neuropsychological dysfunction in MHI cases in the Emergency Room
setting has been emphasized elsewhere [55]. The low referral rate for neuropsycho-
logical testing in cases of mild trauma is unfortunate, given the available evidence
documenting the value of such assessment in assessing the effects of a traumatic brain
injury [56].
The present study suggests that a significant number of patients with a head
injury defined as `mild’ sustain actual structural cerebral damage, thus disputing the
notion that a MHI does not result in any neurologically-based behavioural sequelae.
The authors do not support the position advocating the exclusion of patients from
the MHI group in the presence of positive CT findings [38, 57]. Such position only
serves to perpetuate the belief that a MHI should not result in any brain damage.
Rather, appreciation for the full complexity of a MHI would be better served by
adopting the definition of the Mild Traumatic Brain Injury Committee of the Head
Injury Interdisciplinary Special Interest Group of the American Congress of
Rehabilitation Medicine [58] which does not exclude patients on the grounds of
neuroradiological findings. In the end, the documentation of positive CT findings
in MHI patients brings credibility to the complaints voiced by many MHI patients.
This, in turn, should ensure proper management of this group of patients whose
symptoms are often met with scepticism.
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