Severe closed head injury

Richard S Polin MD (Dr. Polin of George Washington University has no relevant financial relationships to disclose.)
Randolph W Evans MD, editor. (

Dr. Evans of Baylor College of Medicine received honorariums from Allergan, Amgen, Biohaven, Lilly, and Novartis for speaking engagements.

Originally released June 18, 1999; last updated August 22, 2020; expires August 22, 2023


Surgical and medical management of closed head injury continues to evolve. Although no one has yet identified the "magic bullet" to prevent secondary injury after head trauma, several promising novel strategies are being employed. In this update, the author has addressed trials of tranexamic acid for traumatic brain injury.

Key points


• Wartime experience has continuously influenced and improved civilian management of severe traumatic brain injury.


• Predictors of outcome include the Glasgow Coma Scale and Injury Severity Scores and aspects of the neurologic exam of the comatose patient, such as the pupillary exam.


• Contemporary brain injury management has shifted from intense hyperventilation and mannitol administration to maintaining tissue oxygenation and employing hypertonic saline.

Historical note and terminology

Evidence from the antiquities suggests that there were cases of neurosurgical intervention for brain injuries by the Chinese, the Incas, and the Greeks, among others (Jennett 1996). MacEwen described diagnosis and evacuation of a subdural hematoma (Jennett 1976). Much trauma experience has been obtained from war. In specific, Cushing's attention to antisepsis and early debridement produced improved mortality figures in World War I (Cushing 1918). Experience during World War II, the Korean conflict, and the Vietnam War taught neurosurgeons that rapid surgery could produce excellent survival statistics. The 2 most important developments in the evolution of head trauma care have been the introduction of the CT scan by Houndsfield and colleagues in the 1970s and the introduction of the Glasgow Coma Scale by Teasdale and Jennett during the same period (Teasdale 1974). The ability to rapidly diagnose and accurately describe injuries has been extremely beneficial to trauma patients.

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