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perature continues to rise until the end, when there is circulatory collapse In this category of severe cerebral injury, where the patients survive for only a few hours or days, postmortem examination commonly discloses cerebral contusion and focal hemorrhage, necrosis of tissue, and brain swelling In the Traumatic Coma Data Bank, which included 1030 gravely injured patients with Glasgow Coma Scale scores of 8 or less, 21 percent had subdural hematomas, 11 percent had intracerebral clots, and 5 percent had epidural hematomas Notable, however, is the fact that half the patients had no mass lesions on the CT scan On the basis of CT criteria, these patients were thought to have diffuse axonal injury However, in 50 consecutive autopsies of severely injured patients, summarized in an earlier era by Rowbotham, all but two showed macroscopic changes, indicating the relative unreliability of CT analysis The lesions in these cases consisted of surface contusions (48 percent), lacerations of the cerebral cortex (28 percent), subarachnoid hemorrhage (72 percent), subdural hematoma (15 percent), extradural hemorrhage (20 percent), and skull fractures (72 percent) As these gures indicate, several of these changes were found in the same patient Moreover, trauma of extracranial organs and tissues is frequent and obviously contributes to the fatal outcome Among patients who survived and remained vegetative until death, Adams and colleagues (2000) found that 80 percent had thalamic damage and 71 percent had ndings of diffuse axonal injury, as discussed earlier This leaves in somewhat ambiguous status the proximate cause of the persistent vegetative state after blunt head injury, but it does emphasize the frequency of bilateral thalamic damage in cases of the vegetative state from all causes In respect to the second subgroup, ie, the relatively less severe and seldom fatal head injuries, all gradations in tempo and degree of recovery can be observed In the least severely injured of this group, recovery of consciousness begins in a few hours, although there may be a relapse within the rst day or two as a result of swelling of the contused brain tissue, enlargement of a subdural hematoma, brain hemorrhage, or infarction, the last provoked by arterial spasm in relation to subarachnoid hemorrhage The CSF is usually bloody Eventually, recovery may be nearly complete, but the period of traumatic amnesia covers a span of several days or even weeks In this second subgroup, the sequence of clinical events is the same as that described in relation to concussion except that their duration is more protracted Stupor gives way to a confusional state that may last for weeks, and it may for a variable period be associated with aggressive behavior and uncooperativeness (traumatic delirium) The period of traumatic amnesia is proportionately longer than in the less severely injured It is during the period of recovery of consciousness that focal neurologic signs (hemiparesis, aphasia, abulia, etc) become more obvious, though some unilateral signs may have been detected during the comatose period Once the patient improves to the point of being able to converse, he is demonstrably slow in thinking, with few mental associations; unstable in emotional reactions; and faulty in judgment a state sometimes referred to as traumatic dementia Finally there is that relatively small, distressing group of severely brain-injured patients in whom the vital signs become normal but who never regain full consciousness As the weeks pass, the prospects become more bleak Such a patient, especially if a child, may still emerge from coma after 6 to 12 weeks and make a surprisingly good though usually incomplete recovery, but such instances are decidedly rare Some of those who survive for long periods open their eyes and move their heads and eyes from side.

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to side but betray no evidence of seeing or recognizing even the closest members of their families They do not speak and are capable of only primitive postural or re ex withdrawal movements Jennett and Plum referred to this as the persistent vegetative state (see page 305) Fourteen percent of the patients in the Traumatic Coma Data Bank remained in this state Hemiplegia or quadriplegia with varying degrees of decerebrate or decorticate posturing is usually demonstrable Life is mercifully terminated after several months or years by some medical complication Our colleague R D Adams has examined the brains of 14 patients who remained in coma and in vegetative states from one to 14 years All showed extensive zones of necrosis and hemorrhage in the upper brainstem In generalizing about this category of head injury, ie, patients who are and have been comatose from the time of injury, the effects of contusion, hemorrhage, and brain swelling often become evident within 18 to 36 h after the injury and then may progress for several days If the patients survive this period, their chances of dying from complications of these effects such as increased intracranial pressure, herniations of the temporal lobe, subdural hemorrhage, hypoxia, and pneumonia are greatly reduced The mortality rate of those who reach the hospital in coma is about 20 percent, and most of the deaths occur in the rst 12 to 24 h as a result of direct injury to the brain in combination with other nonneurologic injuries Of those alive at 24 h, the overall mortality falls to 7 to 8 percent; after 48 h, only 1 to 2 percent succumb There is some evidence that transfer of such patients to an intensive care unit, where they can be monitored by personnel experienced in the handling of head injury, improves the chances for survival (see further on).

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