title: Traumatic brain injury: patterns of failure of nonoperative management.
abstract: OBJECTIVE
  The circumstances of failure for nonoperative management of blunt traumatic brain injury have been poorly defined. In this study, all trauma patients identified over a 12-year period with progression of neurologic injury requiring craniotomy were retrospectively reviewed.
  
  
  METHODS
  Data collected included demographic information, mechanism of injury, field and admission vital signs, and Glasgow Coma Scale score, medications, associated injuries, and coagulopathy. Head computed tomographic scans were reviewed, and anatomic findings were correlated with clinical changes (change in mental status or elevation of intracranial pressure) that led to subsequent CT scan and craniotomy.
  
  
  RESULTS
  Of 20,100 patients, there were 852 who had computed tomographic scans with acute intracranial injuries on admission; 462 patients were managed nonoperatively. Fifty-seven patients had progression of neurologic injury (34 < 24 hours = early; 23 > 24 hours = late) that required surgery.
  
  
  CONCLUSIONS
  Of the variables investigated, only anatomic location of injury was found to be predictive of early failure of nonoperative management. Frontal intraparenchymal hematomas are particularly prone to early failure. Clinical examination and intracranial pressure monitoring are equally important in detecting failure and should be an integral part of nonoperative management.
authors.affiliation: Department of Surgery, University of California, San Diego, Medical Center, 92103-8896, USA.
authors.forename: N Y
authors.initials: NY
authors.lastname: Patel
authors.forename: D B
authors.initials: DB
authors.lastname: Hoyt
authors.forename: P
authors.initials: P
authors.lastname: Nakaji
authors.forename: L
authors.initials: L
authors.lastname: Marshall
authors.forename: T
authors.initials: T
authors.lastname: Holbrook
authors.forename: R
authors.initials: R
authors.lastname: Coimbra
authors.forename: R J
authors.initials: RJ
authors.lastname: Winchell
authors.forename: A W
authors.initials: AW
authors.lastname: Mikulaschek
mesh_terms: D000328:Adult; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000601:surgery*; D002543:Cerebral Hemorrhage / Q000000981:diagnostic imaging / Q000601:surgery; D003399:Craniotomy; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D019586:Intracranial Hypertension / Q000000981:diagnostic imaging / Q000601:surgery; D008297:Male; D014057:Tomography, X-Ray Computed; D017211:Treatment Failure