mild head injury: a misnomer

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: [email protected]

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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


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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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


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


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


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


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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mild head injury: a misnomer

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