摘要:

&NA;We have analyzed features of patients who had what appeared initially to be a minor head injury but who developed an acute traumatic intracranial hematoma. Over a 10‐year period. 183 patients who were able to open their eyes spontaneously, were oriented to person, place, and time, and who obeyed commands when they were first seen at a hospital subsequently underwent operation for an acute intracranial hematoma. The hematoma was extradural in 54% of these patients. A history of altered consciousness or symptoms of headache and vomiting were present in 61% of the patients: 33% had a focal neurological deficit, and 43% had either focal deficit or signs of a basal skull fracture. A skull fracture was shown radiologically in 60% of patients, including 52% of those not clinically suspected of having an intracranial lesion. Six months after injury, 77% of the patients had made a moderate or good recovery. The possibility that a patient who has recently sustained a head injury might develop an acute intracranial hematoma can never be completely discounted, even when there are no abnormal clinical signs, and a skull x‐ray retains a useful place in the investigation of selected patients with a minor head injury. (Neurosurgery27:669‐673, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;The purpose of the present study was to determine whether early removal of an experimental intracerebral mass altered cerebral blood flow, brain water content, neuropathological findings, or neurological function 24 hours later. In three experimental series, a 50‐&mgr;l balloon was inflated within the right caudate nucleus in rats. At 24 hours after inflation, we studied cerebral blood flow by quantitative autoradiography, brain specific gravity, and qualitative histopathology by light microscopy. The animals were also assessed using a simple neurological deficit scale. In each series, half of the animals had the balloon inflated for 10 minutes (Group 1), and half had the balloon inflated permanently (Group 2). After transient inflation, there were surprisingly small differences in the blood flow between the two cerebral hemispheres at 24 hours. By contrast, in animals with permanent inflation, several indices of blood flow were significantly worse in the hemisphere ipsilateral to the balloon: the mean and median blood flow levels in the caudate nucleus; the mean blood flow in the cerebral cortex; and the area of cortex with ischemic levels of blood flow. The specific gravity was reduced in areas surrounding the site of balloon insertion after either transient or permanent inflation, and there was evidence of ischemic cell damage in all animals studied. These changes were more severe after permanent inflation, but the differences were not significant. Neurological outcome was significantly better after transient as compared with permanent inflation. The present findings contradict previous results and suggest that early removal of an intracerebral mass may have subsequent benefits. (Neurosurgery27:674‐682, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;The Children's Orientation and Amnesia Test (COAT) was developed to assess cognition serially during the early stage of recovery from traumatic brain injury in children and adolescents. The norms for the COAT, which is composed of 16 items evaluating general orientation, temporal orientation, and memory, were defined from data obtained from 146 children aged 3 to 15 years. In 37 patients with head injuries, the duration of posttraumatic amnesia, as indicated by the number of days COAT scores were in the impaired range, was significantly related to both verbal and nonverbal memory at the baseline and 6 and 12 months after injury. COAT scores were a better predictor of verbal and nonverbal memory performance than the Glasgow Coma Scale score at 6 and 12 months after the injury. This study shows that the COAT has adequate reliability and validity as a measure of the duration of posttraumatic amnesia in children and adolescents. (Neurosurgery27:683‐691, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Variables important in predicting the final postsurgical outcome of 435 patients who sustained missile head wounds during the Iran‐Iraq War were evaluated over a 99‐month period. The type of projectile, site of injury, and presence or absence of foreign material did not seem to have a significant effect on the final outcome. Of the patients with a perforating type of injury, 48.8% had a poor surgical outcome as compared with 19.9% with a penetrating type and 15.6% with a tangential type. This difference is statistically significant (x2= 14.7 and 17.1, respectively;p< 0.001). The most important factor in predicting overall outcome was the Glasgow Coma Scale (GCS) score at the time of admission. Mortality and morbidity contributing to a poor surgical outcome were noted in only 6% of patients with a GCS score at admission of 13 to 15, in 24.6% of those with a GCS score of 9 to 12, in 57% of those with a GCS score of 6 to 8, and in 65% of those with a GCS score of 3 to 5. Of the 71 patients who died, 75% had a score of 3 to 8. Perforating projectiles or those traversing two or more dural compartments were statistically significant in contributing to mortality and moribidity (x2= 17.2;p< 0.001). The incidence of focal neurological deficit was 100, 90.6, 88, and 52.2% in patients with GCS scores of 3 to 5, 6 to 8, 9 to 12, and 13 to 15, respectively, The two best predictors of mortality in this group of patients were a low GCS score and infection. (Neurosurgery27:692‐695, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Previous retrospective studies of cranial gunshot wounds have failed to determine whether aggressive field resuscitation. triage to a neurosurgical center, and early surgical intervention can improve the assumed poor outcome of these severely injured patients. Therefore, we studied 100 consecutive patients prospectively to establish a systematic approach to treatment. If the patient retained two or more neurological signs after aggressive field resuscitation/intubation. a computed tomographic scan was performed. Rapid surgical debridement was done unless the patient deteriorated to clinical brain death. The Glasgow Coma Scale (GCS) score after resuscitation was 3 to 5 in 58 patients, 6 to 8 in 8 patients, 9 to 12 in 12 patients, and 13 to 15 in 22 patients. Seventy‐six computed tomographic scans and 43 craniotomies were performed. The Glasgow Outcome Scale scores showed that 60 patients died. 2 were vegetative, 6 were severely disabled, 20 were moderately disabled, and 13 had good outcomes. There were 10 postoperative deaths. No patient with a GCS score of 3 to 5 had a satisfactory outcome; however, outcome progressively improved as the GCS score increased. We conclude that all cranial gunshot patients should initially receive aggressive resuscitation. Patients with stable vital signs should be examined by computed tomographic scan. If the patient's GCS score after resuscitation is 3 to 5 and no operable hematomas are present, then no further therapy should be offered. All patients with a GCS score greater than 5 should receive aggressive surgical therapy. (Neurosurgery27:696‐700, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Median nerve somatosensory evoked potential (SSEP) grades and Glasgow Coma Scale (GSC) scores were obtained from 51 patients with head injuries within 1 week after the injury to determine the relationship of these scores, both individually and combined, to outcome scores obtained more than 6 months after the injury. SSEP grading was based on the presence or absence of the cortical evoked potential, the amplitude of the early cortically generated P22 wave form, and the conduction time through the brain (P/N13‐N20 interpeak latency). SSEP responses from both sides of the brain were combined and graded from 1 to 6. The GCS was graded without the verbal component (maximum score, 10), because all patients were intubated. All patients were unresponsive to commands. Median SSEP grades correlated better with Glasgow Outcome Scale and Barthel Index scores (R= 0.57 and 0.64, respectively;P< 0.00001) than GCS scores did (R= 0.35 and 0.37, respectively,P< 0.00001), and combining SSEP grades and GCS scores did not improve the predictive power of the model (R= 0.57 and 0.64, respectively;P< 0.00001). All SSEP Grade 1 patients (n = 13) either died or remained in a vegetative state. In contrast, all SSEP Grade 6 patients (n = 7) had a moderate disability or good recovery. This study demonstrates the prognostic value of early quantitative median nerve SSEP grading for patients with head injuries who are unresponsive to commands within 1 week after the injury. (Neurosurgery27:701‐708, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Fifty‐one surgical decompressions without nerve transposition for ulnar neuropathy were performed in 46 patients. All of the patients were men with an average age of 59 years at the time of surgery. The follow‐up range was between 5 and 32 months (average, 17.8 months). The disease involved the nondominant arm in 24 patients (52%) and was bilateral in 5 (11%). In 23 cases (50%), no predisposing condition could be identified, whereas 15 patients (33%) abused alcohol and 8 patients (17%) had diabetes mellitus. Fifty‐seven percent of the patients helped by surgery had symptoms for less than 1 year, whereas only 30% of patients with symptoms for more than 1 year had symptomatic improvement. The relative magnitude of the slowing of ulnar nerve conduction velocity across the elbow was not significantly correlated with the success of decompression in relieving symptoms. Ulnar nerve conduction velocities across the elbow were 36.13 ± 11.76 m/s in those responding to surgery and 38.97 ± 13.91 m/s in those not responding (c = 0.06, dF = 50,P< 0.3). A total of 37 patients showed symptomatic improvement after decompression. Simple decompression of the ulnar nerve was performed under local anesthesia without transposition of the nerve. In all of these cases, compression of the nerve occurred predominantly in the epicondylar groove. Narrowing of the nerve in the groove was present in 28 cases (55%): scar tissue was found adhering to the nerve in 21 cases (41%); and two pseudoneuromas were found (4%). Forty‐one operations (80%) resulted in symptomatic improvement, typically noted by the patient within the first month postoperatively. Ten operations (20%) did not result in improvement. Pain and sensory complaints responded best to surgery, whereas patients with significant muscular atrophy generally did not improve. These data indicate that decompression without transposition of the ulnar nerve is effective in the treatment of selected cases of ulnar compressive neuropathy at the elbow. Furthermore, patients with progressive and intractable pain and sensory complaints should be selected for surgery before the development of atrophy, because both a long duration of symptoms and the presence of atrophy indicate a relatively poor prognosis from decompression. (Neurosurgery27:709‐714, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Five cynomolgus monkeys treated with unilateral carotid ligation, renal hypertension, and &bgr;‐aminopropionitrile feeding were studied repeatedly by cerebral angiography to clarify the growth process of saccular cerebral aneurysms. Repeated angiography demonstrated saccular cerebral aneurysms in three of five monkeys; two aneurysms were found 15 months and a third 12 months after the operation. At autopsy, one saccular aneurysm was found to be bilocular in shape, and the others were unilocular. Fusiform aneurysms were also observed in four monkeys. Microscopic studies revealed the walls of the saccular aneurysms were very thin and consisted of fibrous tissue. In one aneurysm, the aneurysmal sac was almost obstructed by a well‐organized thrombus. No evidence of intramural hemorrhage was found in any of the saccular cerebral aneurysms. The conversion of early aneurysmal changes into saccular aneurysms was found in any of the abruptly, and no consistent growth rate was noted. The multiloculation of saccular aneurysms was closely related to the size of an aneurysm. The present study indicates that a saccular cerebral aneurysm may grow abruptly from one of several different kinds of early aneurysmal changes. (Neurosurgery27:715‐720, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;During direct surgery of neoplastic and vascular lesions of the cavernous sinus, the intracavernous carotid artery may be injured beyond repair, or its total isolation may be necessary for surgical management of these lesions. The newly developed procedure of a saphenous vein graft bypass of the cavernous carotid artery allows re‐establishment of carotid circulation. Patients with poor collateral circulation are at high risk for ischemic complications induced by the prolonged temporary occlusion required to perform the bypass graft. Optimal management of these patients is to perform the venous bypass graft for permanent vascularization while maintaining carotid cerebral circulation through an intraoperative shunt. We studied this procedure in cadavers, and three shunt types were evaluated: the external intrapetrous‐supraclinoid shunt (Type A), the internal intrapetrous‐supraclinoid shunt (Type B), and the neck internal carotid‐supraclinoid shunt (Type C). Anatomical landmarks, techniques, distances, caliber, and materials used are presented. The rationale and candidates for such a procedure are discussed. The specifications of an optimal balloon shunt are presented, and the three procedures are compared. (Neurosurgery27:721‐728, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID

摘要:

&NA;Delayed cerebral ischemia is the major cause of death and disability in patients who initially survive an aneurysmal subarachnoid hemorrhage (SAH). In the present study, a protocol for prophylactic hypertensive hypervolemic hemodilution (“triple‐H” therapy) was utilized in the treatment of SAH, and the response of cerebral blood flow (CBF) was evaluated. Serial CBF measurements, f1and CBF15, were performed using the xenon‐133 inhalation technique to maximize therapy. Surgery within 24 hours of subarachnoid hemorrhage was preferred. In 43 patients with SAH, mean hemoglobin and hematocrit were lowered 3.0 ± 0.3 g/dL and 8.9 ± 0.5%, respectively, over the first 24 hours. Mean f1and mean CBF15over the same period increased 34.2 ± 5.8% and 21.2 ± 3.6%, respectively. The maximum mean increase in CBF was 47.2 ± 4.7% for f1and 30.1 ± 3.2% for CBF15. Cerebral blood flow remained elevated during the 21 days after SAH, irrespective of neurological grade on admission, age, sex, or angiographic arterial narrowing. This is the first report of a consistent method for establishing sustained improvement in CBF after SAH. All patients managed in total compliance with the protocol remained neurologically stable or improved. Two patients developed delayed ischemia and infarction because of the inability to sustain protocol requirements. Thirty‐six of the 43 patients (84%) were discharged capable of an independent lifestyle. Triple‐H therapy is a safe and effective modality for elevating and sustaining CBF after SAH. In combination with early aneurysm surgery, it can minimize delayed cerebral ischemia and lead to an improved overall outcome. (Neurosurgery27:729‐740, 1990)

ISSN:0148-396X    

出版商:OVID    

年代:1990

数据来源: OVID