CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF MILD HEAD INJURY (MHI) IN ADULTS

Trauma is considered a leading cause of death in the world and brain injury contributes a significant proportion of that mortality, hence it is a public health emergency. ¹ In Egypt, road traffic accidents continue to represent the primary cause of head injuries, reflecting global trends identified by the World Health Organization (2023). Integrating national data underscores the public health significance of establishing standardized approaches for head injury management. ²

Mild head injury (MHI) is defined as blunt head injury with Glasgow Coma Scale (GCS) score of 13-15 within 30 minutes of injury or at presentation or as a blunt injury to the head which is accompanied with temporary loss of consciousness, amnesia or disorientation/confusion with a Glasgow Coma Score of 13-15.^3,4

Some recommend classifying patients with a GCS score of 13 as moderate head injury (defined as GCS score of 9-12) because they seem more similar with regard to prognosis and incidence of intracranial abnormalities. ^5,6 MHI constitute about 80-90% of all MHI, and may have intracranial pathologies requiring neurosurgical intervention in about 10% of cases, 1% of which could be life-threatening. ⁷

For an industrialized country, estimates of the relative causes of head injury are as follows: motor vehicle accidents (20 to 45 %), falls (30 to 38 %), occupational accidents (10 %), recreational accidents (10 %) and assaults (5 to 17 %). ^8,9 In older adults, falls are more likely the cause, and motor vehicle accidents are more common in the young.

MHI results from direct external contact forces or from the brain being slapped against intracranial surfaces with acceleration/deceleration trauma. Concussion may result in neuropathologic changes, but the acute clinical symptoms are believed to reflect a disturbance of function rather than structural injury. ¹⁰

The acute evaluation of a patient with MHI includes a neurologic assessment and mental status testing. Prolonged unconsciousness (greater than one minute), persistent mental status alterations, or abnormalities on neurologic examination require urgent imaging and neurosurgical consultation.

It is important to note that MHI and concussion may be unrecognized by both the injured and non-medical trained observers, particularly if there is no loss of consciousness.¹¹  Some surveys have found that more than 80 percent of individuals with a past concussion did not recognize it as such. ^12,13

Imaging usually computed tomography (CT) without contrast is recommended for a subset of patients with MHI.  While imaging is normal in patients with a concussion or MHI, studies suggest that there is a sufficient incidence of abnormalities to make imaging worthwhile in a subset of at-risk patients. One systematic review of the literature estimated the prevalence of CT abnormalities of 5% among patients presenting to a hospital with GCS of 15 and 30% for those presenting with a GCS of 13. The incidence of abnormalities leading to neurosurgical intervention was approximately 1%. 5, 14–17