Head-injured patients who talk and deteriorate into coma. Analysis of 211 cases studied with computerized tomography

Evacuation of traumatic intracerebral haematomas using a simplified stereotactic procedure

The authors present a series of 37 traumatic intracerebral haematomas (ICH) evacuated by a simplified stereotactic surgical procedure. The mortality rate was 80% in patients with Glasgow coma scale (G.C.S.) scores of 3-5 and 25% in patients with scores of 6-7. There were no deaths in patients with G.C.S. of 8 or more. With the exception of the first group of patients, the results were better than those achieved by wide craniotomy. The importance of reduced operative trauma in patients with ICH, which often are associated with multifocal or diffuse brain injuries, are discussed.

Documented reversal of global ischemia immediately after removal of an acute subdural hematoma. Report of two cases

The authors report two cases of severe head injury with acute subdural hematoma, in which cerebral blood flow (CBF) and cerebral blood volume (CBV) measurements were obtained prior to evacuation of the subdural hematoma and again immediately after removal. The first patient, a 21-year-old man with a motor response localizing to pain, had a global CBF of 18.2 ml/100 gm/min and a decreased global CBV of 3.7 ml/100 gm at 2.3 hours after injury. Immediately after removal of the subdural hematoma (8.1 hours after injury), CBF and CBV measurements revealed increases to 35.5 ml/100 gm/min and 5.8 ml/100 gm, respectively. The second patient, a 49-year-old woman with a normal flexor motor response to pain, had preoperative global values of 15.8 ml/100 gm/min for CBF and 2.0 ml/100 gm for CBV at 3 hours after injury. Postoperatively (9.3 hours after injury), the CBF and CBV values increased to 41.6 ml/100 gm/min and 4.0 ml/100 gm, respectively. The first patient, with only borderline ischemia and removal of the subdural hematoma within 3 hours, made a good recovery, while the second patient, with prolonged lower levels of CBF, remained in a persistent vegetative state. The low values of preoperative CBV argue for compression of the microcirculation as the cause of ischemia.

Basic fibroblast growth factor messenger RNA is expressed strongly at the acute stage of cerebral contusion

Basic fibroblast growth factor (bFGF) has a neurotrophic effect both in vitro and in vivo, and is considered to play an important role in the maintenance of neuronal functions in the normal brain. Neural damage in brain contusion progresses after the primary injury of trauma because of cerebral hemodynamic and metabolic impairment including intracranial hemorrhage and/or brain swelling. Northern blot analysis of bFGF mRNA was performed in rats after cerebral contusion produced by our modified fluid percussion device. Expression of bFGF mRNA increased significantly on the second day after trauma. A possible role of bFGF is functioning to protect the critical neurons from secondary neural damage in cerebral contusion.

Patients who talk and deteriorate

Patients who "talk and deteriorate" are defined as those who utter recognizable words at some time after head injury and then deteriorate to a severe head-injured condition (Glasgow Coma Scale score of 8 or less) within 48 hours of injury. They represent a very small but important subgroup of patients with brain injury. In approximately 75% of these patients, the cause of this deterioration is intracranial hematoma. Despite the fact that talking indicates nonlethal impact brain injury, deterioration is a marker of poor prognosis. Outcome depends on early recognition of deterioration and rapid removal of mass lesions. The challenge for emergency physicians is to distinguish patients at risk for deterioration from the many patients evaluated after head injury.

Management of low-risk head injuries in an entire area: results of an 18-month survey

All patients admitted following a minor head injury (GCS is without neurological deficits) during an 18 month period in an entire area were submitted to the same diagnostic and therapeutic protocol. Adult patients were x rayed and in the cases with skull fracture (even asymptomatic), a computed tomographic (CT) scan was performed. Children (below the age of 14) did not routinely receive skull X-rays but were admitted to one of the five regional hospitals where a CT scanner was available 24 hours per day. Neuroradiologic investigations (carried out in over 600 patients) showed posttraumatic lesions in 201 cases; 113 of these patients were transferred to the neurosurgical center. There were 49 patients with extradural hematomas, 41 with brain contusions, 17 with depressed skull fractures, and six with subdural hematomas. Of these 113, 40 patients were operated on (mainly extradural hematomas); surgical indications were based on appearance of clinical deterioration, lesion volume, presence of midline shift, and/or compressed third ventricle and basal cisterns. In eight cases there was a clinical deterioration to a GCS of 13 or less; in all of these patients, the CT diagnosis (and transfer to a neurosurgical center, preceded the onset of deterioration. All patients admitted to such a center had a good outcome, but a survey of deaths related to head injury in the area revealed two fatalities following minor head injury. The only avoidable death was a patient with multiple brain contusions who developed sudden brain swelling on day 12 post-trauma. We conclude that, even if management mortality is not zero, our protocol is sufficiently safe for the treatment of minor head injury.

Delayed and progressive brain injury in closed-head trauma: radiological demonstration

The importance of delayed or secondary brain insults in the eventual outcome of closed-head trauma has been documented in experimental models. To understand this phenomenon in the clinical setting, we studied a series of head-injured patients in whom multiple cranial computed tomographic (CT) scans were obtained. Patients whose follow-up CT studies revealed new intracranial lesions or worsening, compared with admission findings, were considered to have delayed cerebral injury. One hundred forty-nine (44.5%) of 337 consecutively studied patients developed delayed brain injury. There were highly significant associations (P < 0.001) between the appearance of delayed cerebral insults and the severity of the initial brain injury, the need for cardiopulmonary resuscitation in the field, the presence of coagulopathy at admission, and subdural hematoma on the initial CT scan. In addition, delayed injury was associated (P < 0.001) with higher mortality, slowed recovery, and poorer outcome at 6 months. Delayed brain injury was not significantly associated with patient age, sex, injury mechanism, associated injury, the need for endotracheal intubation in the field, early talking, CT abnormality other than intracranial hematoma, or type of residual neurological deficits. We used multiple regression analysis to explore the relationship between severity of injury, delayed insults, and outcome. As expected, the severity of the initial brain trauma contributed significantly to neurological outcome. The presence of delayed cerebral injury makes the outcome dramatically worse for each category of initial injury severity. The relationship between initial and secondary brain injury is discussed.