Correspondence (reply): In Reply

My thanks go to the correspondents and their professional and helpful comments. Prof. Schmidt adds from an ophthalmologist‘s perspective further possible disorders of pupillary and ocular function. MRI scanning has recently confirmed that pupillary unresponsiveness is indicative of brain injury (1). However, even in the past, larger clinical series reported in 7% of cases pupils unilaterally unresponsive to light with intracranial bleeds on the contralateral side (2). As example 2 from the article shows, pupillary dysfunction can be caused not only by subdural or epidural hematoma, but also by brain swelling and contused brain tissue (2, 3).

Prof. Maegele expresses concern that the cover page, with a motorcycle helmet lying on the tarmac, might suggest that acute head injury affects only young motorcyclists who are prepared to take risks. I am convinced that the editors of Deutsches Ärzteblatt did not intend to communicate an epidemiological message by putting the helmet on the cover. I can certainly agree with the point made, that the average age of patients with acute head injury is rising—this is obviously a consequence of the increase in the average age of Germany‘s population. I also agree that treatment results over recent decades have not improved—the available literature certainly supports that. Computed tomography scanning—the crucial imaging technique in this setting—has been available for 40 years. However, whereas the imaging procedure in 1978 took about 1 hour, the same image can now be obtained within 10 seconds. Treatment strategies have not changed fundamentally. As decompressive craniectomy has been found helpful in stroke patients, it is now also used in acute head injury. Whether this will help a statistical improvement in outcomes remains to be seen.

Neuropathologist Dr. Barz focuses on the pathophysiological process of space occupying intracranial lesions after traumatic head injury. His point, that epidural hematomata may develop slowly and gradually, is of utmost practical importance and gave rise to the recommendation in the guidelines of the Association of Scientific Medical Societies in Germany (Arbeitsgemeinschaft wissenschaftlicher medizinischer Fachgesellschaften, AWMF), that no more than 1 hour after the accident should pass before imaging is obtained, ideally a CT scan, because an epidural hematoma usually reaches its space occupying size after 1 hour at the earliest—sometimes even later. The hematoma should be drained/reduced not only in an “organ sparing“ way, as the neuropathologist requests—this is self-evident for neurosurgeons—but primarily in a timely fashion, before a functional brain lesion turns into irreversible morphological damage (see Figure 1 in the article).