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        Trauma is the most common cause of death in young people, and head injury accounts for almost half of these trauma-related deaths. The medical prognosis following head injury depends upon the area and severity of brain damage.

        Some guide to prognosis is provided by the mental status, since loss of consciousness for more than one or two minutes implies a worse condition. Similarly, the grade of retrograde and posttraumatic memory loss provides an indication of the severity of injury and this of the prognosis. Absence of skull fracture does not rule out the possibility of severe head injury. During the physical examination, special attention should be given to then condition of consciousness and extent of any brain stem malfunction, Dr S Sathya-narayanan of Sri Chakra Hospital Medical Education and Research Centre in suburban Nanganallur says.

        Patients who have lost memory for two minutes or more following head injury should be hospitalised for observation, as should patients with focal neurologic defects, lethargy, or skull fracture. If admission is declined, responsible family members should be given clear instructions about the need for, and manner of, checking on them at regular (hourly) intervals and for obtaining additional medical assistance if necessary.

        Skull radiographs or CT scans may provide proof of fractures. Because injury to the spine may have accompanied head trauma, cervical spine radiographs (especially in the lateral projection) should always be obtained in comatose patients and in patients with severe neck pain or a deficit possibly related to cord compression. CT scanning has an important role in demonstrating intracranial hemorrhage and may also provide evidence of cerebral edema and displacement of midline structures.

        Scalp injuries and skull fractures

        Scalp lacerations and depressed or compound depressed skull fractures should be treated surgically as appropriate. Simple skull fractures require no specific treatment.

        The clinical signs of basilar skull fracture include bruising about the orbit (raccoon sign), blood in the external auditory meatus (Battle's sign), and leakage of cerebrospinal fluid (which can be identified by its glucose content) from the ear or nose. Cranial nerve palsies (involving especially the first, second, third, fourth, fifth, seventh and eighth nerves in any combination) may also occur. If there is any leakage of cerebrospinal fluid, conservative treatment, with elevation of the head, restriction of fluids, and administration of acetazolamide (250 mg four times daily), is often helpful; but if the leak continues for more than a few days, lumbar subarachnoid drainage may be necessary. Antibiotics are given if infection occurs, based on culture and sensitivity studies. Only very occasional patients require intracranial repair of the dural defect because of persistence of the leak or recurrent meningitis.

        Late complications of head injury

        The relationship of chronic subdural hemorrhage to head injury is not always clear. In many elderly persons there is no history of trauma, but in other cases a head injury, often trivial, precedes the onset of symptoms by several weeks. The clinical presentation is usually with mental changes such as slowness, drowsiness, headache, confusion, memory disturbances, personality change, or even dementia. Focal neurologic deficits such as hemiparesis or hemi-sensory disturbance may also occur but are less common. CT scan is an important means of detecting the hematoma, which is sometimes bilateral. Treatment is by surgical evacuation to prevent cerebral compression and tentorial herniation. There is no clear evidence that prophylactic anticonvulsant therapy reduces the incidence of posttraumatic seizures.