Introduction1

Head injury defines an injury to the head and brain. Hence, injury to head which does not involve the brain, is not considered as head injury. It is not unusual for a neurosurgeons to get a call for treating a head injured patient from casualty, which turn out to be a simple case of scalp laceration or scalp hematoma. It means the people who send a calls to neurosurgeons do not even know, what is head injury. This occurs at small as well as large hospitals like AIIMS. It indicates, how casual is our approach towards diagnosis of head injury, a condition, which not only all doctors should know, but even general public must know. Hence, when a doctor is confronted with a situation, he must know, if the patient he is dealing with has or has not suffered from head injury.

Head injury is a neurosurgical problem, and operation if required, should be performed by a neurosurgeon. However, the question then remains, is it practically possible that every head injury can be seen, diagnosed and treated by neurosurgeon? This has been possible in US, Japan and many other countries where the trained personnels are available. In 3rd world countries it is not possible due to lack of facilities. For example, India with more than 1250 million people have over 1200 neurosurgeons.^1,2 Mostly, the neurosurgeons are available in metropolis or Govt. Medical College-based cities. Even today large number of our medical colleges do not have neurosurgical facilities. Hence, where is the question of district or subdivisional hospitals having the facility. Similarly in Nepal, for 30 million people there are only 6 to 8 neurosurgeons as compared to Japan, where for 130 million people there are over 6000 neurosurgeons. While in Oman there are 10 neurosurgeons for 2 million population. This means, in India and other developing countries, head injury has to be primarily managed by general surgeons, with a adequate (6 months to 1 year) training in head injury management.⁵

I remember my undergraduate days, when no one taught us anything about head injury. When a severe head injury patient got admitted in the general surgical wards in coma, we used to inform patient's relatives poor prognosis and 0 percent chance of survival.¹ The scenario is changed in large cities with improved educational standard and medical facilities. Whereas conditions are more or less same in small towns. It is not out of place to mention that 35 years have passed since I completed my MBBS. The medical college still does not have a neurosurgeon. The entire city, with a population of one million lacks a neurosurgeon. This is the ground reality in many medical colleges in India.

In Delhi, over 2200 people died due to road accidents in 1997¹ also in 2000 and over 15000 had nonfatal head injury and the number is increasing. Recently, over 2 to 3 years the incidence of head injury has fallen in Delhi 10 percent every year. This is basically because, strict implementation of helmet, seat belt, and banning of old vehicle to operate in Delhi road. Introduction of CNG uses has also helped in reduction of accidents. What is surprising, however, in many large cities like Bangalore, Chennai, Ahmedabad, Lucknow, Kanpur, Pune and Trivandrum, etc. helmet is not still compulsory for two wheeler driver.

Large number of young people die, which does not evoke much reaction except occasional photos and write up in newspapers. School bus accidents have rocked India in last few years and there were several incidents in Delhi. People react, discuss for 2few days then forget, till another school bus disaster takes place. Our authorities and public have become immune to elicit any response. Unfortunately, a death occurring outside India gets much more attention and publicity, like Raman Lamba's case, who died in Dhaka due to cricket ball injury or Indian people dieing in Australia. There was a great deal of reaction by the press people. While similar incidences occurring in India does not gets any attention. I must tell, I have seen and managed many cricket ball injuries to head, including major and minor. I have operated patients with clot following cricket ball injury. Unfortunately,

I have also seen many children, who became blind following the head injury by a cricket ball.

A Study to see the trends in head injury mortality among 0 to 14 years in Scotland revealed that the children residing in less affluent areas seems to be at relatively greater risk of sustaining fatal head injury than their affluent counterpart.¹⁰ It means that the affluency and availability of health services at a reasonable distance also have bearing in the outcome of head injury.

All above emphasize the concern and need for proper management of head injury. Hence, it is important for all medical graduates and even public to have some knowledge of head injuries. Most important among that is, how to define head injury? As I have mentioned a head injury is synonymus with brain injury and the telltale evidence of head injury is loss of consciousness. Even if patient does not loose consciousness, he or she must have altered consciousness, it means patient is not fully conscious and oriented. Sometimes, it may be difficult to know whether a patient had really lost consciousness or not. If a patient developed memory loss for the events following the injury it is 100 percent certain that the patient had lost consciousness. The period following injury when a patient fails to register the events, despite of being conscious and alert, is called post-traumatic amnesia (PTA). Thus, PTA is a sure shot evidence of head injury. After having defined head injury it is worth at this stage to classify head injury. Head injury by and large is classified as: (a) minor, (b) moderate, and (c) severe. In a simple way one can say, head injury is minor, when loss of consciousness is for less than 30 minutes, it is moderate, if the duration of unconsciousness is between 30 minutes and 6 hours. If the duration of unconsciousness is longer than 6 hours, head injury is categorized as severe (Tables 1.1A and B). Fortunately 80 percent head injuries are minor.⁶ However, I must state here is that “No head injury is minor enough to be neglected nor severe enough to be given up”, Each head injury must be treated according to its own merit. I have personally seen large number of patients, whom the neurosurgeons had written off, they not only survived but also become alright. Sadly enough, this situation is rare, nevertheless, few examples only remind us to do our best, even if a patient is bad and carries a small chance of survival.^11,12

Large number of factors determine the outcome in a head injury patients. Age, sex, severity of injury, intracranial pathology (Figs 1.1A to D), intracranial pressure and associated injuries are few significant prognostic factors (Fig. 1.2). Recently, genetic basis of head injury outcome is reported. Presence of Apolipoprotein E4 alleles is recognized as a poor prognostic factor. Patients who are homozygous or heterozygous for APO E4 allele have 14 times greater likelyhood of having poor outcome.^7–10

All above facts emphasis a sound theoretical and practical knowledge on head injury management. There is a tremendous degree of nonuniformity in management of head injury, not only between general surgeons and neurosurgeons, but also the difference is apparent between neurosurgeons, depending on experience, availability of facilities and even between nonpracticing and practicing neurosurgeons.

Overall, with tremendous increase in number of head injury, the management of head injury has gained an important place today. There are only a few books written on head injury by Indian authors. Hence, we visualized the need for a comprehensive books on head injury, which would provide overall knowledge on head injury, However, I must confess that, head injury is a vast subject and there is growing literature on various aspects of head injury. From this point of view no book can provide everything on the subject, however, having said that and knowing fully our limitations, we have made a venture to bring out this book only to provide our students and trainee an adequate knowledge on head injury management.