Abstract: Modern understanding and care of head injuries began in the 1960s when artificial ventilation, originating in use in polio, was applied to severely injured victims. The impetus to research and advances in management is still evolving. Better understanding of the pathology and patho-physiology of traumatic brain damage identified the fundamental structural and functional components. The distinction between primary and secondary damage pointed to the reduction of avoidable deaths and disability as the target of many efforts in management. Reliable clinical assessment and with the Glasgow Coma Scale, advances in intracranial imaging and their combination in guidelines such as those of SIGN and NICE have had clear success in the early diagnosis and surgery for intracranial haematoma. Outcome has also been improved by better management of extra cranial complications through trauma systems and intensive care. Despite extensive fundamental research, less progress has been made in the “neuroprotective” management of primary diffuse damage resulting from axonal shearing or from the consequences of ischaemic insults. The recognition that survivors of intensive care could face substantial subsequent problems led to the need to move beyond mortality as an index of outcome. The multi-dimensional consequences of brain damage, spanning mental, physical and social fields led to the creation of many descriptive systems and classifications. It is important to recognise the purpose for which each was introduced. The Glasgow outcome scale was developed to provide a short, simple overview categorisation, particularly applicable to groups of patients. The approach has proved valuable in research linking outcome to early severity, in developing predictive systems and in comparing series of patients managed in different ways. Its utility has been advanced by the development of an extended and structured, more consistent approach. Although initially introduced for severe injuries, a prospective study of a representative cohort of all head injuries admitted to hospital showed that it is able to portray the consequences of even so called mild injury, including the remarkably high incidence and persistence of incomplete recovery. The factors leading to this, the influence of adverse “emotional indices” and their potential amelioration are a priority for further research, as is the high rate of mortality, which continues for many years after the acute stage.
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