Severe Craniocerebral Trauma: What is the life expectancy?

Life expectancy after a severe craniocerebral trauma depends on many factors.

The Glasgow Coma Scale (GCS) is used to classify degrees of severity. In this widely used international clinical classification, points are awarded for the patient’s reaction, including eye opening (1–4), speech (1–5), and motor reactions (1–6), and the total score is determined by summation. A score of 15 indicates no disturbance of consciousness, while a score of 13–15 indicates mild craniocerebral trauma. Such a trauma occurs, for example, in the case of a concussion, which can heal without consequence after treatment of symptoms. A score of 9–12 points indicates a moderate craniocerebral trauma, while a score of 3–8 points indicates severe craniocerebral trauma.

In cases of severe craniocerebral trauma, 30–40% of patients die following the accident, while 2–14% remain in a coma-like state.

Around 10–30% are subsequently severely disabled, and only 7–27% recover well from the consequences of their trauma.

Risk factors for a poor outcome include the mechanism of injury and primary and secondary brain damage. Moreover, patients with craniocerebral trauma often have serious concomitant injuries. Fifteen percent suffer from concomitant spinal damage, which can include spinal cord injuries. However, abdominal and thoracic trauma, as well as multiple fractures, are also associated with polytrauma.

It is often difficult to predict the outcome in the early stages, but prompt treatment and long-term rehabilitation can improve the patient’s prognosis.

Below, we discuss the prognosis, rehabilitation, and long-term course of treatment for patients with severe craniocerebral trauma.

Severe Head Injury or Severe Craniocerebral Trauma: Life Expectancy Prognoses

A severe head injury significantly impacts life expectancy, which depends primarily on the extent of the damage and secondarily on further care and the progression of the injury.

In the event of polytrauma, the patient is transported (by ambulance or helicopter) to a diagnostic center as quickly as possible after their airways have been cleared and circulation has been stabilized. A CT scan is performed there.

If a space-occupying cerebral hemorrhage is present, such as an epidural or subdural hematoma, it must be relieved quickly through surgery.

An epidural hematoma can be caused by a skull fracture if the meningeal artery is torn off, which puts pressure on the cerebrum from the outside. Survival requires rapid relief by means of a craniotomy, which involves cutting open the skull and removing blood from the dura. The bone flap can often be reinserted. In cases of an acute subdural hematoma, the brain damage is often more severe due to the brain shifting to the opposite side. In addition, an impact to the head can lead to brain contusions, which are caused by direct impact and often occur on the opposite side of the skull as contrecoup lesions.

Diffuse axonal injury is also relevant to the prognosis. This is often caused by high-speed trauma, which destroys axons and brain cells due to shearing injuries.

Diffuse axonal injury cannot be seen with certainty on CCT. However, an MRI can detect punctiform hemorrhages, which are often located in the basal ganglia, corpus callosum, and brain stem. If this type of brain damage is present in the brain stem area, the patient’s prognosis is poor. The mortality rate is ten times higher if there is damage to the brain stem. If patients survive, they are comatose and unable to interact with their environment.

The exact clinical picture depends on the location of the damage, which may be caused by minor bleeding or a brain stem tumor.

Initial signs include deep unconsciousness involving the midbrain, which can manifest as flexion and extension synergisms.

How does brain swelling go down?

Whether a brain swelling recedes or persists over a longer period of time influences the progression of brain damage. In addition to the initial brain injury, secondary brain swelling, known as edema, is a determining factor for the outcome. This involves general swelling of the brain in the first few days after the trauma. The rigid skull creates a space problem, which increases intracranial pressure.The goal of intensive care therapy is to reduce this pressure while ensuring sufficient blood flow to the brain.

One way to reduce intracranial pressure is to drain cerebrospinal fluid via an external ventricular drain. To do this, a hole is drilled into the front right part of the skull with a craniotome, and a thin tube is placed into the cerebrospinal fluid chamber. The evoDrill from evonos can be used for this procedure. It is a particularly sharp drill available in various sizes that can quickly perforate the top of the skull without applying force. At the same time, intracranial pressure can be measured continuously via an EVD.

General measures can be used to treat brain swelling. These include elevating the upper body, maintaining normothermia, and adopting a Minimal Handling approach, which involves handling the patient as little and as gently as possible. Mannitol or NaCl can be administered to reduce intracranial pressure. If brain perfusion is maintained, mild hyperventilation can be performed. In addition, anesthesia can be intensified by increasing the dosage of anesthetics. As a final conservative measure, barbiturate treatment can be initiated.

If these measures fail to reduce intracranial pressure, decompressive craniectomy can be performed as a last resort.

This procedure involves removing the top of the skull, creating a dural flap, and allowing the brain to expand, which prevents incarceration.

If the patient survives the critical phase, the bone flap can be reinserted once the brain has subsided. If available, the patient’s own bone flap can be fixated again to the skull using mini plates. If the patient’s bone flap is not available, a cranioplasty can be performed. For this purpose, an individually adapted flap, such as the evoShape from evonos, is created using a thin-layer CCT. The precise fit reduces operating time and increases patient safety during refitting. This plastic flap is fixated in place with plates and screws (e.g., evoFix from evonos), which are available in different shapes and lengths to ensure an optimal hold.

Once the swelling has subsided, it must be determined whether the patient needs a permanent cerebrospinal fluid (CSF) drain or can manage without one.

If there is a build-up, the EVD is removed and a ventriculoperitoneal shunt is placed permanently. This shunt transports cerebrospinal fluid from the brain to the abdominal cavity via a thin tube placed under the skin.

How long does it take to heal from a severe craniocerebral trauma?

The recovery period after a severe craniocerebral trauma (SCT) varies greatly from person to person and requires a long rehabilitation process that spans months or even years.

Initially, the patient receives intensive care. If they require long-term artificial respiration, they undergo tracheostomy while in an induced coma. This eliminates the need for a breathing tube in the mouth or nose, allowing the patient to be weaned off the ventilator more quickly. If there is no severe brain swelling, sedation is reduced so the patient can regain consciousness.

However, if the brain stem is affected, it can lead to severe, permanent loss of consciousness. Some patients remain in a comatose state.

Following an intensive care unit stay, treatment continues in an early rehabilitation ward. This is where patients with severe brain damage who have undergone tracheostomy and need to relearn basic functions, such as swallowing and speaking, can be treated.

At a later stage, specific neurological rehabilitation is required.

Patients with strokes or chronic neurological diseases, such as multiple sclerosis (MS), Alzheimer’s, and Parkinson’s, are also treated here.

Organic brain damage can severely alter the personality of affected patients. Previously unknown aggression and impulsivity disorders may develop, especially when the frontal lobe is damaged. These disorders can be a major burden for patients and their social environments.

Multidisciplinary cooperation is necessary to help patients with brain injuries recover and for the restoration of brain functions, whether due to trauma or other illnesses, such as brain tumors. Perseverance is also key for patients and their families given the often lengthy recovery period. Due to the long intensive care period, as well as immunosuppression, infections and other setbacks may occur repeatedly during rehabilitation.

What are the long-term effects of a severe craniocerebral trauma?

In addition to the immediate consequences, patients may experience long-term effects that occur several years later.

A study by the Hannelore Kohl Foundation and the Barmer health insurance company monitored 7.7 million people for up to 10 years, over a period of almost 15 years.

Those affected suffered from headaches five times more frequently than patients in the control group who were comparable in age and gender and had pre-existing conditions such as diabetes, heart failure, and rheumatism, but had not experienced a craniocerebral trauma.

It was also shown that endocrine disorders caused by injuries to the pituitary gland occurred more frequently than in the comparison group. These disorders can manifest as fatigue, exhaustion, and loss of libido. In the long term, headaches, migraines, depression, anxiety and sleep disorders also occur more frequently.

Subsequent outpatient treatment is challenging because individual symptoms, such as headaches, tinnitus, dizziness, neck pain and concentration problems, usually persist after a craniocerebral trauma. It is often difficult to find a neuropsychological connection for the affected patients.

However, severe craniocerebral trauma is often followed by more serious consequential damage. Post-traumatic epilepsy requires neurological treatment. And the paralysis, speech disorders and concentration problems that often accompany it make it difficult for patients to regain their independence, and require further treatment.

At all stages of rehabilitation, the patient’s social environment and the level of support and motivation they receive play a significant role. Depending on the patient’s condition and the severity of the disability, long-term care at home or in an institution may be necessary.

In the event of damage to the brain stem, permanent ventilation or other intensive care may be necessary. These patients require specialized care facilities or 24-hour caregivers in their homes. There is an urgent need to expand the corresponding infrastructure in both inpatient and outpatient settings.

Due to the serious prognosis and severe consequential damage caused by severe craniocerebral trauma, accident prevention is becoming increasingly important. Severe craniocerebral trauma is the leading cause of death, especially among young adults. In addition to bicycle helmets, which are now commonplace, especially for children, it would also be beneficial to implement traffic policy measures. Older patients, whose reaction time decreases, and road users under the influence of alcohol, are also at high risk of brain trauma in an accident.