Impact of ICP instability and hypotension on outcome in patients with severe head trauma

1991 ◽  
Vol 75 (Supplement) ◽  
pp. S59-S66 ◽  
Author(s):  
Anthony Marmarou ◽  
Randy L. Anderson ◽  
John D. Ward ◽  
Sung C. Choi ◽  
Harold F. Young ◽  
...  
Keyword(s):  
Head Trauma ◽  
Perfusion Pressure ◽  
Data Bank ◽  
Cutoff Point ◽  
Intensity Level ◽  
Severe Head Trauma ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Number Of Patients ◽  
Fine Print

✓ This study describes the relationship between raised intracranial pressure (ICP), hypotension, and outcome from severe head injury. The study is based on information derived from the Traumatic Coma Data Bank where ICP records from a relatively large number of patients were available to help delineate the major factors influencing outcome. From the total data base of 1030 patients, 428 met minimum monitoring duration criteria for inclusion in the present analysis. Outcome was classified according to the Glasgow Outcome Scale score determined at 6 months postinjury. Arrays of comparably defined summary measures describing the patient's course were considered for ICP, blood pressure (BP), central perfusion pressure, and therapy intensity level. For instance, the array of ICP summary descriptors included the proportion of ICP readings greater than x, for x = 0 to 80 mm Hg by increments of 5 mm Hg. A total of 187 candidate summary descriptors were considered. A stepwise ordinal logistic regression was used to select the subset of candidate summary descriptors that best explained the 6-month outcome. As established previously, age, admission motor score, and abnormal pupils were each highly significant in explaining outcome. Beyond these factors, the proportion of hourly ICP readings greater than 20 mm Hg was next selected and was also highly significant in explaining outcome (p < 0.0001). In addition to the ICP factor, the cutoff point of 20 mm Hg was selected by the procedure as most indicative of outcome. With these four factors modeled, the next selected factor was the proportion of hourly BP readings less than 80 mm Hg. Again, the BP factor was highly significant in explaining outcome (p < 0.0001). As with the ICP factor, the BP cutoff point of 80 mm Hg was objectively selected as most indicative of outcome. In summary, the incidence of mortality and morbidity resulting from severe head trauma is strongly related to raised ICP and hypotension measured during the course of ICP management. Moreover, these ICP and BP factors provide a better indication of outcome than the similarly defined factors of central perfusion pressure or therapy intensity level.

Clinicopathological investigation of gyral high density on computerized tomography following severe head injury in children

1995 ◽  
Vol 82 (6) ◽  
pp. 995-1001 ◽  
Author(s):  
Takehide Onuma ◽  
Yasuko Shimosegawa ◽  
Motonobu Kameyama ◽  
Hiroaki Arai ◽  
Kiyoshi Ishii
Keyword(s):  
Computerized Tomography ◽  
Head Trauma ◽  
Brain Atrophy ◽  
High Density ◽  
Ct Scans ◽  
Severe Head Trauma ◽  
Content Type ◽  
Subacute Stage ◽  
Fine Print ◽  
Diffuse Brain

✓ The authors have treated five cases of severe head trauma in children in which abnormally high density along gyri, “gyral high density,” was seen on plain computerized tomography (CT) scans in the subacute stage of the injury. The prognosis in all cases was poor, with either severe disability or a vegetative state as the outcome due to significant brain atrophy following gyral high density. This pathology was classified into three clinical stages: 1) acute stage, cerebral ischemia in which there is diffuse low density of the cerebrum on CT scans (most marked on the 3rd and 4th days); 2) subacute stage, hemorrhagic infarction showing gyral high density on plain CT scans (between 1 and 4 weeks); and 3) chronic stage, brain atrophy (beginning 4 weeks after the trauma). In their consecutive series of head-injured patients (516 children, 1459 adults), the authors did not find gyral high density on CT scan in adults. This is probably due to the fact that adults who suffer the severe head trauma associated with diffuse brain swelling or diffuse brain edema cannot survive, thus making this gyral high density unique to children.

The treatment of posttraumatic tremor by stereotactic surgery

1994 ◽  
Vol 80 (5) ◽  
pp. 810-819 ◽  
Author(s):  
Joachim K. Krauss ◽  
Mohsen Mohadjer ◽  
Fritz Nobbe ◽  
Fritz Mundinger
Keyword(s):  
Head Trauma ◽  
Functional Disability ◽  
Rating Scale ◽  
Stereotactic Surgery ◽  
Long Term Results ◽  
Severe Head Trauma ◽  
Content Type ◽  
Fine Print

✓ The authors report the long-term results of stereotactic surgery for severe posttraumatic appendicular tremor in 35 patients. The tremors developed after severe head trauma in 33 patients (94%) and after mild to moderate head trauma in two (6%). In all but one, the tremor was most evident during activity. The amplitude of the kinetic tremor was greater than 5 cm in 33 patients (94%) and greater than 12 cm in 19 patients (54%). All were severely incapacitated in their daily living activities due to the tremors. The 35 patients underwent 42 stereotactic operations; five patients were reoperated on the same side and two were treated with a bilateral staged procedure. The contralateral zona incerta was the stereotactic target in 12 patients and was targeted in combination with the base of the ventrolateral (oroventral) thalamus in 23 patients. Long-term postoperative follow-up review was obtained in 32 patients (mean follow-up period 10.5 years). Persistent improvement of tremor was noted in 88%. The tremor was absent or markedly reduced in 65%. Functional disability was assessed and quantified with a modified form of an established rating scale for patients with tremor; it was reduced from a mean value of 57% of maximum disability to 37% over the long term (p < 0.001). Follow-up lesion assessment was obtained in 18 patients by multiplanar magnetic resonance imaging and at autopsy in one patient whose death was unrelated to surgery. As in previous studies, the frequency of persistent side effects was relatively high (38%). These consisted mainly of aggravation of preoperative symptoms. The results are compared to those of a total of 55 patients reported from 1960 to 1992. The occurrence of dystonia and dystonic postures is discussed. Stereotactic surgery is a powerful tool to alleviate posttraumatic tremor and to improve functional disability. However, as there is considerable risk of persistent morbidity in patients after severe head trauma, the operation should be restricted to selected cases with disabling tremor.

Pituitary failure secondary to head trauma

1976 ◽  
Vol 44 (4) ◽  
pp. 504-505 ◽  
Author(s):  
William W. Winternitz ◽  
James A. Dzur
Keyword(s):  
Growth Hormone ◽  
Head Trauma ◽  
Anterior Pituitary ◽  
Follicle Stimulating Hormone ◽  
Thyroid Stimulating Hormone ◽  
Severe Head Trauma ◽  
Content Type ◽  
Hypothalamic Control ◽  
Fine Print ◽  
Stimulating Hormone

✓ A patient presented with hypopituitarism, 2 years after severe head trauma. Deficits of growth hormone, follicle-stimulating hormone, luteinizing hormone, and borderline thyroid-stimulating hormone (TSH) were demonstrated. Normal TSH-releasing hormone (TRH) response and elevated prolactin indicated viable anterior pituitary tissue with inadequate hypothalamic control. Precautions are suggested for recognition and treatment of this syndrome.

Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm

1997 ◽  
Vol 87 (1) ◽  
pp. 9-19 ◽  
Author(s):  
Neil A. Martin ◽  
Ravish V. Patwardhan ◽  
Michael J. Alexander ◽  
Cynthia Zane Africk ◽  
Jae Hong Lee ◽  
...  
Keyword(s):  
Head Trauma ◽  
Craniocerebral Trauma ◽  
Phase Iii ◽  
Severe Head Trauma ◽  
Content Type ◽  
Cerebral Hemodynamic ◽  
Normal Mean ◽  
Time Courses ◽  
Fine Print

✓ The extent and timing of posttraumatic cerebral hemodynamic disturbances have significant implications for the monitoring and treatment of patients with head injury. This prospective study of cerebral blood flow (CBF) (measured using 133Xe clearance) and transcranial Doppler (TCD) measurements in 125 patients with severe head trauma has defined three distinct hemodynamic phases during the first 2 weeks after injury. The phases are further characterized by measurements of cerebral arteriovenous oxygen difference (AVDO2) and cerebral metabolic rate of oxygen (CMRO2). Phase I (hypoperfusion phase) occurs on the day of injury (Day 0) and is defined by a low CBF15 calculated from cerebral clearance curves integrated to 15 minutes (mean CBF15 32.3 ± 2 ml/100 g/minute), normal middle cerebral artery (MCA) velocity (mean VMCA 56.7 ± 2.9 cm/second), normal hemispheric index ([HI], mean HI 1.67 ± 0.11), and normal AVDO2 (mean AVDO2 5.4 ± 0.5 vol%). The CMRO2 is approximately 50% of normal (mean CMRO2 1.77 ± 0.18 ml/100 g/minute) during this phase and remains depressed during the second and third phases. In Phase II (hyperemia phase, Days 1–3), CBF increases (46.8 ± 3 ml/100 g/minute), AVDO2 falls (3.8 ± 0.1 vol%), VMCA rises (86 ± 3.7 cm/second), and the HI remains less than 3 (2.41 ± 0.1). In Phase III (vasospasm phase, Days 4–15), there is a fall in CBF (35.7 ± 3.8 ml/100 g/minute), a further increase in VMCA (96.7 ± 6.3 cm/second), and a pronounced rise in the HI (2.87 ± 0.22). This is the first study in which CBF, metabolic, and TCD measurements are combined to define the characteristics and time courses of, and to suggest etiological factors for, the distinct cerebral hemodynamic phases that occur after severe craniocerebral trauma. This research is consistent with and builds on the findings of previous investigations and may provide a useful temporal framework for the organization of existing knowledge regarding posttraumatic cerebrovascular and metabolic pathophysiology.

NINDS Traumatic Coma Data Bank: intracranial pressure monitoring methodology

1991 ◽  
Vol 75 (Supplement) ◽  
pp. S21-S27 ◽  
Author(s):  
Anthony Marmarou ◽  
Randy L. Anderson ◽  
John D. Ward ◽  
Sung C. Choi ◽  
Harold F. Young ◽  
...  
Keyword(s):  
Intracranial Pressure ◽  
Data Bank ◽  
The United States ◽  
Physiological Data ◽  
Intensity Level ◽  
Content Type ◽  
Head Injured ◽  
Traumatic Coma ◽  
Injured Patients ◽  
Fine Print

✓ This report describes the methods used by the Traumatic Coma Data Bank (TCDB) for acquisition and recording of intracranial pressure (ICP) data of severely head-injured patients. Direct computerization of physiological data from all four participating locations within the United States and transmission to a central data bank was found to be logistically complex and costly. A simple manual method for recording ICP, blood pressure, and concomitant ICP therapy at the bedside is described. The method documents the temporal course of these variables for the duration of monitoring. The importance of relating ICP to the therapy intensity level used for ICP management is emphasized. Concomitant analysis of the therapy intensity level is considered imperative in correlative patient studies. The methods described in this report have been in use among all four TCDB hospitals. Examples of ICP data retrieved from the TCDB are presented to illustrate the adequacy of the methods for assessing temporal trends. Of 1030 patients admitted to the TCDB, 654 severely head-injured patients had at least 4 hours of monitoring recorded; elevated ICP (> 20 mm Hg) was observed in 72% of these 654 patients.

A new rat model of chronic cerebral hypoperfusion associated with arteriovenous malformations

2002 ◽  
Vol 97 (5) ◽  
pp. 1198-1202 ◽  
Author(s):  
Jian Hai ◽  
Meixiu Ding ◽  
Zhilin Guo ◽  
Bingyu Wang
Keyword(s):  
Electron Microscopy ◽  
Animal Model ◽  
Arteriovenous Malformations ◽  
Perfusion Pressure ◽  
Chronic Cerebral Hypoperfusion ◽  
Cerebral Hypoperfusion ◽  
Model Group ◽  
Content Type ◽  
The Right ◽  
Fine Print

Object. A new experimental model of chronic cerebral hypoperfusion was developed to study the effects of systemic arterial shunting and obstruction of the primary vessel that drains intracranial venous blood on cerebral perfusion pressure (CPP), as well as cerebral pathological changes during restoration of normal perfusion pressure. Methods. Twenty-four Sprague—Dawley rats were randomly assigned to either a sham-operated group, an arteriovenous fistula (AVF) group, or a model group (eight rats each). The animal model was readied by creating a fistula through an end-to-side anastomosis between the right distal external jugular vein (EJV) and the ispilateral common carotid artery (CCA), followed by ligation of the left vein draining the transverse sinus and bilateral external carotid arteries. Systemic mean arterial pressure (MAP), draining vein pressure (DVP), and CPP were monitored and compared among the three groups preoperatively, immediately postoperatively, and again 90 days later. Following occlusion of the fistula after a 90-day interval, blood—brain barrier (BBB) disruption and water content in the right cortical tissues of the middle cerebral artery territory were confirmed and also quantified with transmission electron microscopy. Formation of a fistula resulted in significant decreases in MAP and CPP, and a significant increase in DVP in the AVF and model groups. Ninety days later, there were still significant increases in DVP and decreases in CPP in the model group compared with the other groups (p < 0.05). Damage to the BBB and brain edema were noted in animals in the model group during restoration of normal perfusion pressure by occlusion of the fistula. Electron microscopy studies revealed cerebral vasogenic edema and/or hemorrhage in various amounts, which correlated with absent astrocytic foot processes surrounding some cerebral capillaries. Conclusions. The results demonstrated that an end-to-side anastomosis between the distal EJV and CCA can induce a decrease in CPP, whereas a further chronic state of cerebral hypoperfusion may be caused by venous outflow restriction, which is associated with perfusion pressure breakthrough. This animal model conforms to the basic hemodynamic characteristics of human cerebral arteriovenous malformations.

The use of intraarterial papaverine in the management of vasospasm complicating arteriovenous malformation resection

1995 ◽  
Vol 82 (2) ◽  
pp. 296-299 ◽  
Author(s):  
Michael K. Morgan ◽  
Maurice J. Day ◽  
Nicholas Little ◽  
Verity Grinnell ◽  
William Sorby
Keyword(s):  
Arteriovenous Malformation ◽  
Perfusion Pressure ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Venous Occlusion ◽  
Neurological Deterioration ◽  
Unusual Complication ◽  
Content Type ◽  
First Case ◽  
Normal Perfusion Pressure Breakthrough ◽  
Fine Print

✓ The authors report two cases of treatment by intraarterial papaverine of cerebral vasospasm complicating the resection of an arteriovenous malformation (AVM). Both cases had successful reversal of vasospasm documented on angiography. In the first case sustained neurological improvement occurred, resulting in a normal outcome by the time of discharge. In the second case, neurological deterioration occurred with the development of cerebral edema. This complication was thought to be due to normal perfusion pressure breakthrough, on the basis of angiographic arterial vasodilation and increased cerebral blood flow. These two cases illustrate an unusual complication of surgery for AVMs and demonstrate that vasospasm (along with intracranial hemorrhage, venous occlusion, and normal perfusion pressure breakthrough) should be considered in the differential diagnosis of delayed neurological deterioration following resection of these lesions. Although intraarterial papaverine may be successful in dilating spastic arteries, it may also result in pathologically high flows following AVM resection. However, this complication has not been seen in our experience of treating aneurysmal subarachnoid hemorrhage by this technique.

Dose—response tolerance of the visual pathways and cranial nerves of the cavernous sinus to stereotactic radiosurgery

1998 ◽  
Vol 88 (1) ◽  
pp. 43-50 ◽  
Author(s):  
Klaus A. Leber ◽  
Jutta Berglöff ◽  
Gerhard Pendl
Keyword(s):  
Stereotactic Radiosurgery ◽  
Cavernous Sinus ◽  
Dose Response ◽  
Cranial Nerves ◽  
Visual Pathways ◽  
Content Type ◽  
Number Of Patients ◽  
Response Tolerance ◽  
Fine Print

As the number of patients treated with stereotactic radiosurgery increases, it becomes particularly important to define with precision adverse effects on distinct structures of the nervous system. Object. This study was designed to assess the dose—response tolerance of the visual pathways and cranial nerves after exposure of the cavernous sinus to radiation. Methods. A total of 66 sites in the visual system and 210 cranial nerves of the middle cranial fossa were investigated in 50 patients who had undergone gamma knife treatment for benign skull base tumors. The mean follow-up period was 40 months (range 24–60 months). Follow-up examinations consisted of neurological, neuroradiological, and neuroophthalmological evaluations. The actuarial incidence of optic neuropathy was zero for patients who received a radiation dose of less than 10 Gy, 26.7% for patients receiving a dose in the range of 10 to less than 15 Gy, and 77.8% for those who received doses of 15 Gy or more (p < 0.0001). Previously impaired vision improved in 25.8% and was unchanged in 51.5% of patients. No sign of neuropathy was seen in patients whose cranial nerves of the cavernous sinus received radiation doses of between 5 and 30 Gy. Because tumor control appeared to have been achieved in 98% of the patients, the deterioration in visual function cannot be attributed to tumor progression. Conclusions. The structures of the visual pathways (the optic nerve, chiasm, and tract) exhibit a much higher sensitivity to single-fraction radiation than other cranial nerves, and their particular dose—response characteristics can be defined. In contrast, the oculomotor and trigeminal nerves have a much higher dose tolerance.

Late results of radical excision of craniopharyngiomas in children

1975 ◽  
Vol 42 (1) ◽  
pp. 86-90 ◽  
Author(s):  
Edward L. Katz
Keyword(s):  
High Mortality ◽  
Surgical Excision ◽  
Late Results ◽  
Radical Excision ◽  
Initial Operation ◽  
Content Type ◽  
Mortality And Morbidity ◽  
Fine Print

✓ The results of radical surgical excision of craniopharyngiomas in children operated on by Dr. Donald Matson beginning in 1950 are presented. The patients are analyzed in regard to survival and quality of survival. While 22 of 34 children so treated at the initial operation are presently alive and tumor-free, high mortality and morbidity followed in cases where reoperation was performed. Properly treated endocrinological deficits need not be a serious problem, but persistent hyperosmolality carried a grave prognosis. No predictive criteria are yet available to determine which tumors are amenable to radical surgical excision.

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