Decerebrate rigidity in acute head injury

A systematic review and meta-analysis on abnormal posturing among brain injury patients

BACKGROUND

 Abnormal motor posturing (AMP), exhibiting as decorticate, decerebrate, or opisthotonos, is regularly noticed among children and adults.

OBJECTIVE

 This systematic review and meta-analysis examined the risk factors and outcome of posturing among severe head and brain injury subjects.

METHODS

 Based on the inclusion and exclusion criteria and using MeSH terms: "decerebrate posturing", "opisthotonic posturing", "brain injury", and/or "cerebral injury" articles were searched on Scopus, PubMed, Science Direct, and google scholar databases. Observational studies, case series, and case reports were included.

RESULTS

 A total of 1953 studies were retrieved initially, and based on the selection criteria, 20 studies were finally selected for review and were analyzed for meta-analysis based on the mortality between the hematomas. The functional outcomes of this study are the risk factors, mortality rate and Glasgow Outcome Scale. Decerebrative patients were higher among the studies related to head injury surgeries. Males were mainly treated for decerebrate postures compared with the female subjects. Extradural hematoma and acute subdural hematoma with cerebral contusion were quite common in the surgical mass lesions.

CONCLUSION

 The findings reported that the lesion types, the operative procedures, and the age of the decerebrating patients with brain injuries are the significant prognostic factors determining the survival outcomes.

Bilateral tonic seizures vs. bilateral tonic events in critically ill patients: differences in semiology

PURPOSE

Our primary aim was to analyze bilateral epileptic tonic seizures (ETS) and bilateral non-epileptic tonic events (NTE) in critically ill patients. Our secondary aim was to analyze ETS per their epileptogenic zone.

METHODS

We performed a retrospective analysis of clinical signs in patients with bilateral ETS and NTE. Two authors independently reviewed 34 videos of ETS in 34 patients and 15 videos of NTEs in 15 patients. Initial screening and review was performed in an unblinded manner. Subsequently, the semiology was characterized independently and blindly by a co-author. Statistical analysis was conducted using Bonferroni correction and two-tailed Fischer exact test. Positive predictive value (PPV) was calculated for all signs. Cluster analysis of signs with a PPV >80% was performed to evaluate co-occurring semiological features in the two groups.

RESULTS

Compared to patients with ETS, those with NTEs more frequently had predominant involvement of proximal upper extremities (UE) (67% vs. 21%), internal rotation of UE (67% vs. 3%), adduction of UE (80% vs. 6%) and bilateral elbow extension (80% vs. 6%). In contrast, those with ETS more frequently had abduction of UE (82% vs 0%), elevation of UE (91% vs. 33%), open eyelids (74% vs. 20%), and involvement of both proximal and distal UE (79% vs. 27%). In addition, seizures that remained symmetrical throughout were more likely to have a generalized onset than focal (38% vs. 6%), p = 0.032, PPV 86%.

CONCLUSIONS

A careful analysis of semiology can often help differentiate between ETS and NTE in the ICU. The combination of eyelids open, upper extremity abduction, and elevation reached a PPV of 100% for ETS. The combination of bilateral arms extension, internal rotation, and adduction reached a PPV of 90.9% for NTE.

Impact of Chronological Age and Biological Sex on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A CAnadian High-Resolution TBI (CAHR-TBI) Study

Impaired cerebrovascular reactivity has emerged as an important associate with poor long-term outcome after moderate/severe traumatic brain injury (TBI). However, our understanding of what drives or modulates the degree of impaired cerebrovascular function remains poor. Age and biological sex remain important modifiers of cerebrovascular function in health and disease, yet their impact on cerebrovascular reactivity after TBI remains unclear. The aim of this study was to explore subgroup responses based on age and biological sex on cerebral physiology. Data from 283 TBI patients from the CAnadian High Resolution TBI (CAHR-TBI) Research Collaborative were evaluated. Cerebrovascular reactivity was determined using high-frequency cerebral physiology for the derivation of three intracranial pressure (ICP) based indices: (1). PRx - correlation between ICP and mean arterial pressure (MAP), (2). PAx - correlation between pulse amplitude of ICP (AMP) and MAP and (3). RAC - correlation between AMP and cerebral perfusion pressure (CPP). Insult burden (% time above clinically defined thresholds) were calculated for these indices. These cerebral physiology indices were studied for their relationship with age via linear regression, age trichotomization (< 40, 40 - 60, > 60) and decades of age (< 30, 30 - 39, 40 - 49, 50 - 59, 60 - 69, > 69) schemes. Similarly, differences based on biological sex were assessed. A statistically significant positive linear correlation was found between PAx, RAC and age. In corollary, a statistically significant relationship was found between increasing age on trichotomized and decades of age analysis with PAx and RAC measures. PRx failed to demonstrate such relationships to advancing age. There was no clear difference in cerebrovascular reactivity profiles between biological sex categories. These findings suggest that AMP-based cerebrovascular reactivity indices may be better positioned to detect impairment in TBI patients with advancing age. Further investigation into the utility of PAx and RAC is required, as they may prove useful for certain subgroups of patients.

Impact of Age and Biological Sex on Cerebrovascular Reactivity in Adult Moderate/Severe Traumatic Brain Injury: An Exploratory Analysis

Age and biological sex are two potential important modifiers of cerebrovascular reactivity post-traumatic brain injury (TBI) requiring close evaluation for potential subgroup responses. The goal of this study was to provide a preliminary exploratory analysis of the impact of age and biological sex on measures of cerebrovascular function in moderate/severe TBI. Forty-nine patients from the prospectively maintained TBI database at the University of Manitoba with archived high-frequency digital cerebral physiology were evaluated. Cerebrovascular reactivity indices were derived as follows: PRx (correlation between intracranial pressure [ICP] and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). Time above clinically significant thresholds for each index was calculated over different periods of the acute intensive care unit stay. The association between PRx, PAx, and RAC measures with age was assessed using linear regression, and an age trichotomization scheme (<40, 40-60, >60) using Kruskal-Wallis testing. Similarly, association with biological sex was tested using Mann-Whitney U testing. Biological sex did not demonstrate an impact on any measures of cerebrovascular reactivity. Linear regression between age and PAx and RAC demonstrated a statistically significant positive linear relationship. Median PAx and RAC measures between trichotomized age categories demonstrated statistically significant increases with advancing age. The PRx failed to demonstrate any statistically significant relationship with age in this cohort, suggesting that in elderly patients with controlled ICP, PAx and RAC may be better metrics for detecting impaired cerebrovascular reactivity. Biological sex appears to not be associated with differences in cerebrovascular reactivity in this cohort. The PRx performed the worst in detecting impaired cerebrovascular reactivity in those with advanced age, where PAx and RAC appear to have excelled. Future work is required to validate these findings and explore the utility of different cerebrovascular reactivity indices.

Abnormal Motor Response Associated With Concussive Injuries: Biomechanical Comparison Between Impact Seizures and Loss of Consciousness

CONTEXT

Loss of consciousness (LOC) and impact seizures associated with concussion represent different clinical presentations of concussion; however, they are often investigated and treated similarly. The biomechanical parameters differentiating these 2 distinct signs of injury are poorly described.

OBJECTIVE

To differentiate between cases of concussions with LOC and those with impact seizures by comparing the impact velocity, peak linear and peak rotational acceleration, as well as brain tissue deformation in the cerebral cortex, white matter, brainstem, cerebellum, thalamus, and corpus callosum.

DESIGN

Descriptive laboratory study.

PATIENTS OR OTHER PARTICIPANTS

Elite American football players who sustained an LOC (n = 20) or impact seizures (n = 21).

MAIN OUTCOME MEASURE(S)

Impact velocity, peak linear and peak rotational acceleration, maximum principal strain, cumulative strain damage measure at 10%, and strain rate (SR).

RESULTS

The SR in the cerebral white matter was greater in the LOC group than in the impact-seizure group. Similar trends were observed for SRs in the cerebral cortex, brainstem, and corpus callosum. No differences were present between groups for the other variables in this study.

CONCLUSIONS

A lower SR in certain brain regions helps to explain why motor function is preserved and can be observed in patients with impact seizures versus LOC from concussive injuries.

Optic neuropathy and decorticate-like posture as presenting symptoms of Bickerstaff's brainstem encephalitis: A case report and literature review

A 72-year-old woman with a 10-day history of bilateral visual impairment after respiratory tract infection showed decorticate-like posture and progressive deterioration of consciousness leading to coma. Ophthalmoplegia was also noted and anti-GQ1b antibodies were positive, consistent with Bickerstaff's brainstem encephalitis. After intravenous immunoglobulin and steroid pulse therapy, her consciousness gradually improved. However, severe visual impairment at the level of hand motion was noticed, which gradually normalized after second steroid pulse therapy. Atypical findings including optic neuropathy and decorticate-like posture can be seen in patients with Bickerstaff's brainstem encephalitis, and early diagnosis is essential for adequate management.

Outcome of surgery for operable supratentorial mass lesions in patients presenting with decerebration following severe head injury: A retrospective analysis of factors affecting outcome

AIM

Abnormal motor response in the form of decerebration signifies either injury or compression of brain stem. The presence of decerebrate rigidity following head injury is a grave prognostic sign. Mortality may increase up to 70% in patients showing signs of decerebration. Although many studies have identified the prognostic factors in severe head injuries, few studies have focused on the operated patients with decerebration in predicting the long-term outcome. This study was planned to determine the outcome in this group of patients for prognostication and to help plan further line of management.

MATERIALS AND METHODS

All the patients admitted with severe head injury with decerebration (M2 motor response) admitted in neurosurgery department from September 2009 to January 2011 were included in the study. All the patients had operable supratentorial mass lesions with no direct evidence of brain stem damage. Patients with penetrating injury and diffuse injury with no operative mass lesions were excluded from the study. Clinical and computerized tomography (CT) data were correlated with outcome retrospectively. Glasgow outcome scale (GOS) was used as a measure of functional outcome.

RESULTS

The patients admitted with decerebration (M2 motor response) comprised 8% of the total head injury related operative procedures performed at our institute during the period. Of the 72 patients, 14 (19%) patients were more than 60 years old and 21% (15) were females. The surgical mass lesions comprised extradural hematoma in 27 (38%), cerebral contusions in 19 (26%), acute Subdural Hematoma alone in 7 (10%), and acute Subdural Hematoma (SDH) with cerebral contusion in 19 (26%) of the patients. Of the 72 patients, 36(50%) were operated within 24 hours of injury Follow-up of all, but 2 (3%) was obtained. Favorable outcome (GOS 4 and 5) was obtained in 14% (n = 10) of the patients with 83% (n = 60) mortality rate. The favorable outcome rate among the patients operated for Extradural Hematoma was 26% and for cerebral contusions was 11%. Only 5% of the patients operated for acute SDH survived.

CONCLUSION

Radiological diagnosis (type of lesion), followed by duration of decerebration and age of the patient are the most important prognostic factors determining the outcome of surgery in decerebrating patients. Our results confirm that despite the poor prognosis in decerebrate patients, a significant number of patients may still survive and have a good outcome.

Autoerotic nonlethal filmed hangings: a case series and comments on the estimation of the time to irreversibility in hanging

Recent studies of filmed hangings have documented the agonic sequences in these deaths. Considering this agonic sequence, one question comes to mind: which of these responses is an indicator of irreversible damage? Since decerebrate rigidity points toward lesions of the midbrain, it was initially thought that this posture could be an indicator of severe potentially irreversible damage. However, we here present a series of nonlethal filmed hangings by a 35-year-old male autoerotic practitioner, which will prove otherwise: in a film of an interrupted hanging, a decerebrate pattern of rigidity was observed at 20 seconds. However, the man later regained consciousness and seemed to present a full recovery without any noticeable symptoms. The scientific basis for the generalized assumption that death by hanging occur in 3 to 5 minutes will be reviewed. Though this estimation of the time is certainly precise and accurate enough for the needs of clinicians, it will be demonstrated that scientific evidence are not strong enough to be used in court. So how long does it take to suffer irreversible damage by hanging or by strangulation? The only honest and scientifically valid answer seems to be that we do not know.

Prognostic significance of age in traumatic brain injury

BACKGROUND

Age is a strong prognostic factor following traumatic brain injury (TBI), with discrepancies defining the critical prognostic age threshold. This study was undertaken to determine the impact of various age thresholds on outcome after TBI.

MATERIALS AND METHODS

The ages of patients admitted with TBI were prospectively studied in relation to mode of injury, Glasgow coma score (GCS), CT category and surgical intervention. Mortality was assessed at 1 month, and neurological outcome was assessed at 6 months. Appropriate statistical analyzes (details in article) were performed.

RESULTS

Of the total 244 patients enrolled, 144 patients had severe, 38 patients had moderate and 62 patients had mild TBI, respectively. Age had significant association with grade of injury, CT category and surgical intervention (P < 0.01). Mortality at 1 month was significantly associated with increasing age with patients dead at 1 month being 15% for age < 18, 44% for age between 18 and 59 years, and 52% in the age group > 59 years respectively (P < 0.001). Unfavorable outcome showed significant association with an increase in age, every decade (P < 0.001). In multivariate analysis, there was stepwise increase in the odds of unfavorable outcome across age groups centered on 40 years, independent of confounding factors. The adjusted odds ratios for unfavorable outcome with regard to age thresholds 30, 40 and 50 years were 11.3, 53.3 and 1171, respectively (P < 0.005). Moreover, there was significant association of unfavorable outcome with age > 40 years in all subgroups, based on GCS and surgical intervention (P < 0.05).

CONCLUSIONS

In patients with TBI, age demonstrates independent association with unfavorable outcome at 6 months, in stepwise manner centered on a threshold of 40 years.

Prognostic significance of age in traumatic brain injury

BACKGROUND

Age is a strong prognostic factor following traumatic brain injury (TBI), with discrepancies defining the critical prognostic age threshold. This study was undertaken to determine the impact of various age thresholds on outcome after TBI.

MATERIALS AND METHODS

The ages of patients admitted with TBI were prospectively studied in relation to mode of injury, Glasgow coma score (GCS), CT category and surgical intervention. Mortality was assessed at 1 month, and neurological outcome was assessed at 6 months. Appropriate statistical analyzes (details in article) were performed.

RESULTS

Of the total 244 patients enrolled, 144 patients had severe, 38 patients had moderate and 62 patients had mild TBI, respectively. Age had significant association with grade of injury, CT category and surgical intervention (P < 0.01). Mortality at 1 month was significantly associated with increasing age with patients dead at 1 month being 15% for age < 18, 44% for age between 18 and 59 years, and 52% in the age group > 59 years respectively (P < 0.001). Unfavorable outcome showed significant association with an increase in age, every decade (P < 0.001). In multivariate analysis, there was stepwise increase in the odds of unfavorable outcome across age groups centered on 40 years, independent of confounding factors. The adjusted odds ratios for unfavorable outcome with regard to age thresholds 30, 40 and 50 years were 11.3, 53.3 and 1171, respectively (P < 0.005). Moreover, there was significant association of unfavorable outcome with age > 40 years in all subgroups, based on GCS and surgical intervention (P < 0.05).

CONCLUSIONS

In patients with TBI, age demonstrates independent association with unfavorable outcome at 6 months, in stepwise manner centered on a threshold of 40 years.

150 years of treating severe traumatic brain injury: a systematic review of progress in mortality

Considerable effort and resources have been devoted to preserving life in patients with severe closed traumatic brain injury (TBI). We sought to identify temporal trends in mortality rates of these patients from the late 1800s to the present. We searched the literature for articles on severe TBI, abstracting numbers of patients studied, numbers of deaths, and years of patient entry. Mortality rates were calculated for each study, and meta-regression was used to pool data and to test for significant temporal trends. We reviewed 207 case series comprising more than 140,000 cases of severe closed TBI admitted to hospital over a span of almost 150 years. Since the late 1800s mortality has fallen by almost 50%. However, the rate has varied considerably among the four epochs chosen. Between 1885 and 1930, mortality decreased at a rate of 3% per decade. From 1970 to 1990, mortality declined at a rate of 9% per decade. Both changes are significant. There was no observed improvement in mortality between 1930 and 1970, nor is progress evident since 1990. The authors discuss possible reasons for the apparently intermittent progress in TBI survival over time.

Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury

OBJECT

Despite being common practice for decades and being recommended by national guidelines, aggressive monitoring and treatment of patients with severe traumatic brain injury (TBI) have not been supported by convincing evidence.

METHODS

The authors reviewed trials and case series reported after 1970 in which patients were treated for severe closed TBI, and mortality rates and favorable outcomes at 6 months after injury were analyzed. The patient groups were divided into those with and without intracranial pressure (ICP) monitoring and intensive therapy, and the authors performed a meta-analysis to assess the effects of treatment intensity on outcome.

RESULTS

Although the mortality rate fell during the years reviewed, it was consistently approximately 12% lower among patients in the intense treatment group (p < 0.001). Favorable outcomes did not change significantly over time, and were 6% higher among the aggressively treated patients (p = 0.0105).

CONCLUSIONS

Aggressive ICP monitoring and treatment of patients with severe TBI is associated with a statistically significant improvement in outcome. This improvement occurs independently of temporal effects.

Prognostic value of demographic characteristics in traumatic brain injury: results from the IMPACT study

Outcome following traumatic brain injury (TBI) is not only dependent on the nature and severity of injury and subsequent treatment, but also on constituent characteristics of injured individuals. We aimed to describe and quantify the relationship between demographic characteristics and six month outcome assessed by the Glasgow Outcome Scale (GOS) after TBI. Individual patient data on age (n = 8719), gender (n = 8720), race (n = 5320), and education (n = 2201) were extracted from eight therapeutic Phase III randomized clinical trials and three surveys in moderate or severe TBI, contained in the IMPACT database. The strength of prognostic effects was analyzed with binary and proportional odds regression analysis and expressed as an odds ratio. Age was analyzed as a continuous variable with spline functions, and the odds ratio calculated over the difference between the 75 th and 25 th percentiles. Associations with other predictors were explored. Increasing age was strongly related to poorer outcome (OR 2.14; 95% CI 2.00-2.28) in a continuous fashion that could be approximated by a linear function. No gender differences in outcome were found (OR: 1.01; CI 0.92-1.11), and exploratory analysis failed to show any gender/age interaction. The studies included predominantly Caucasians (83%); outcome in black patients was poorer relative to this group (OR 1.30; CI 1.09-1.56). This relationship was sustained on adjusted analyses, and requires further study into mediating factors. Higher levels of education were weakly related to a better outcome (OR: 0.70; CI 0.52-0.94). On multivariable analysis adjusting for age, motor score, and pupils, the prognostic effect of race and education were sustained. We conclude that outcome following TBI is dependent on age, race, to a lesser extent on education, but not on gender.

Behavioral evaluation of consciousness in severe brain damage

This paper reviews the current state of bedside behavioral assessment in brain-damaged patients with impaired consciousness (coma, vegetative state, minimally conscious state). As misdiagnosis in this field is unfortunately very frequent, we first discuss a number of fundamental principles of clinical evaluation that should guide the assessment of consciousness in brain-damaged patients in order to avoid confusion between vegetative state and minimally conscious state. The role of standardized behavioral assessment tools is particularly stressed. The second part of this paper reviews existing behavioral assessment techniques of consciousness, showing that there are actually a large number of these scales. After a discussion of the most widely used scale, the Glasgow Coma Scale, we present several new promising tools that show higher sensitivity and reliability for detecting subtle signs of recovery of consciousness in the post-acute setting.

A hypothesis accounting for the inconsistent benefit of glucocorticoid therapy in closed head trauma

Because of disagreement between clinical studies, the American College of Neurological Surgeons (ACNS) most recent recommendation (1996) is that glucocorticoids should not be used in the treatment of closed head trauma (CHT). The current paper reviews clinical studies of glucocorticoids and CHT in order to examine what factors might have accounted for the inconsistent results leading to the ACNS's recommendation. A careful analysIs of these studies reveals that, contrary to the ACNS's sweeping conclusion, the available data support the use of glucocorticoids for patients with CHT, but only in specific cases. Glucocorticoids may be beneficial in the treatment of CHT uncomplicated by intracranial hemorrhage; in situations where intracranial hemorrhage accompanies CHT, glucocorticoid treatment appears detrimental. The second part of this paper examines possible mechanisms accounting for the differential effectiveness of glucocorticoids in CHT patients with and without intracranial hemorrhage. These mechanisms include vasospasm, free radical damage, blood-borne factors, and glutamate neurotoxicity.

The Brain Trauma Foundation. The American Association of Neurological Surgeons. The Joint Section on Neurotrauma and Critical Care. Age

Age is a strong factor influencing both mortality and morbidity. Despite some contradictions, most literature supports children faring better than adults who have severe brain injury. The significant influence of age upon outcome is not explained by the increased frequency of systemic complications or intracerebral hematomas with age. Increasing age is a strong independent factor in prognosis, with a significant increase in poor outcome above 60 years of age.

Coma and confusional states: emergency diagnosis and management

Coma and confusion signal a failure of brain function with many possible causes. Since many of the potential causes may quickly lead to death or severe disability, it is important to develop a focused and ordered approach to facilitate the rapid diagnosis and early institution of proper therapies. This requires an understanding of the localizing features of the neurologic examination and of the syndromes likely to cause coma and confusion, a predetermined plan for empiric therapies in certain cases of doubt when diagnostic confirmation will be delayed, and a careful consideration of cases when the diagnosis is not revealed by the initial neuroimaging, lumbar puncture, or EEG.

Predicting survival from head trauma 24 hours after injury: a practical method with therapeutic implications

OBJECTIVE

To develop a method to predict long-term outcome after head injury and determine if outcome can be accurately predicted 24 hours after injury.

DESIGN

A retrospective review was performed on a study cohort of 672 head-injured patients admitted in coma (Glascow Coma Scale score < or = 8) who remained comatose for at least 6 hours, survived more than 24 hours, and had 6-month outcome data available. Stepwise logistic regression analysis was used to determine which clinical variables predicted 6-month outcome. Statistically significant clinical predictors were combined into a single examination variable (MPX score), which reflected a rank-ordering of examinations from worst to best, which was then further weighted by patient age. The relation between 6-month outcome and MPX score at admission and 24 hours was plotted and analyzed.

MEASUREMENT AND MAIN RESULTS

Age, best motor score, and pupillary reactivity at admission and 24 hours were significant predictors of outcome; extraocular motility was predictive at 24 hours only. Age was the most important independent predictor, followed by best motor score, pupillary reactivity, and extraocular motility. Combining these predictors into MPX score resulted in a set of graphs that reliably predicted long-term outcome. The 24-hour MPX data were better predictors of 6-month outcome and were more specific in predicting negative outcomes than admission data.

CONCLUSIONS

The method is simple to use, relying on bedside neurologic examination and a single graph, but appears to predict long-term outcome accurately as early as 24 hours after head injury. If validated on other large series of patients, this method could provide an objective and practical basis for terminating care in patients unlikely to survive a head injury.

Predictive value of brain-stem auditory evoked potentials in children with post-traumatic coma produced by diffuse brain injury

In the present study, brain-stem auditory evoked potentials (BAEPs) in 31 children in post-traumatic coma with diffuse brain injury were examined. The BAEPs were recorded in the first 72 h after hospital admission and the findings of 29 patients related to the level of neurological recovery at 6 months after head injury. On the basis of the results, children were divided into three groups: the first consisted of children with bilateral and normal BAEPs (n = 19); the second of those with asymmetrical BAEPs (n = 6); and the third of those in whom BAEPs has disappeared or in whom only responses of the seventh cranial nerve and cochlear nucleus were recorded (n = 4). All the patients in the first group presented a good clinical outcome, with excellent recovery in 80%. In the second group three children (42.8%) had a good recovery, two (28.6%) were moderately disabled and one (14.3%) died of extraneurological causes. All the patients in the third group died. Abnormal BAEPs showed a significant correlation with absence of pupillary and/or corneal reflex, but not with the Glasgow Coma Score and anisocoria. Good statistical correlation was observed between normal BAEPs and visualization of basal cisterns on computed tomographic scan. The incidence of increased intracranial pressure was higher in patients with abnormal BAEPs, but the differences were not significant (P = 0.06). Our study confirms the predictive value of BAEPs in children's post-traumatic coma due to diffuse brain injury.

Repeated decompressive craniectomy after head injury in children: two successful cases as result of improved neuromonitoring

BACKGROUND Decompressive craniectomy in the treatment of posttraumatic brain swelling is not generally accepted. Until now the efficacy of operative decompressive craniectomy in posttraumatic brain swelling of children appeared more promising. However, the criteria for such procedures remain unclearly defined. METHODS We present two children who had repeated decompressive craniectomy following head injury, in order to control intracranial pressure (ICP) sufficiently. Our indications for performing a decompressive craniectomy in the presence of conservatively uncontrollable raised ICP are: (1) Patient is between the ages of 3 and 35 years. (2) An initial Glasgow Coma Scale (GCS) ranging between 4 and 8. (3) Three criteria have to be fulfilled at the same time: The cerebral perfusion pressure (CPP) has to drop to values of less than 60 mm Hg. It is impossible to control the ICP values (up to 45 mm Hg) conservatively. The diastolic velocity of the transcranial doppler sonography (TCD) has to decrease until only a systolic flow pattern is obtained. (4) No other mass lesion should be detected on cranial computed tomography (CCT) that could account for the rise in pressure. In both cases we performed bifrontal decompressive craniectomies. RESULTS Both patients survived. Seven months after the accident, patient No. 1 was oriented and could walk on her own with a mild right-side hemiparesis. Patient No. 2 could attend school 12 months postinjury. Both patients developed hygromas after the craniectomy. A shunt operation, however, was not necessary. CONCLUSIONS ICP monitoring, together with CCT examination, simultaneous recording of TCD, and systemic parameters, will reveal a patient at risk at a time when impending damage due to uncontrollable ICP may still be prevented. The simultaneous assessment of cerebral blood flow by transcranial doppler (TCD), in this situation, proves most valuable. It improves the guidelines of patient selection for decompressive craniectomy, in the presence of conservatively uncontrollable ICP.

The Brigham Diary of Loyal Davis: a portrait of Harvey Cushing and a neurosurgical acolyte

At 27 years of age, Loyal Davis wrote the Brigham Diary while training as an Associate in Surgery with Dr. Harvey Cushing. The diary is a daily record of the Cushing neurosurgical service between 1923 and 1924. The literary tone of the document is one of youthful enthusiasm and candor. Its contemporary portrayal of Harvard University's third Moseley Professor displays a demanding surgeon and scholar whose primary concern was the care of his patients and who taught the meticulous techniques of neurosurgery by example. In contrast to the experiences offered by current neurosurgical residency programs, Loyal Davis examined 107 patients, observed 81 operations, assisted Dr. Cushing during 23 operations, assisted Dr. Gilbert Horrax in 13 operations, and never performed an operation independently during his year at the Peter Bent Brigham Hospital. Despite these technical constraints, the young assistant learned the Cushing method of surgery and skilled patient care and was encouraged to continue laboratory investigations. Davis also emulated Cushing's exacting method of preparation of medical manuscripts, which were characterized by scientific innovation and an engaging literary style. The diary shows that Cushing often held inflexible surgical and scientific opinions and was contentious in their defense. These opinions were modified only when he was presented with unequivocal facts. The young surgeon sought Cushing's approval which carried a genuine but restrained benevolence. Harvey Cushing's impression on Davis was lasting and profound. The diary conveys the philosophy that uncompromised discipline is a necessary virtue and hard work is full satisfaction in itself. In the following years, Loyal Davis systematically patterned his surgical and scholarly endeavors after those of Harvey Cushing, an exemplar whose unstinting resolve was the pursuit of excellence.

The effect of age on motor and cognitive deficits after traumatic brain injury in rats

Age is one of the most important predictors of outcome after human traumatic brain injury. This study used fluid percussion brain injury to investigate the effects of aging on outcome after brain injury in rats. Three-month-old (n = 8) and 20-month-old (n = 11) rats were injured at a low level (1.7-1.8 atm) of fluid percussion brain injury or received a sham injury (n = 6 for both age groups). Body weight and motor function (beam balance and beam walking) were assessed before injury and for the first 5 days after injury. Cognitive outcome was assessed with the Morris water maze on Days 11 to 15 after injury. Injury did not produce significant weight loss in either age group. At the low level of brain injury used in this study, the 3-month-old rats did not demonstrate any significant motor deficits on the beam-balance or beam-walking tasks. However, the 20-month-old rats displayed significant beam-balance deficits on each of the 5 postinjury test days and significant beam-walking deficits for the first 3 postinjury days. Although Morris water maze performance was impaired in both age groups, the magnitude of impairment was greater in the aged animals. These data demonstrate that traumatic brain injury in the aged animal is marked by increased motor and cognitive deficits, in the absence of pronounced compromise of the animal's general health.(ABSTRACT TRUNCATED AT 250 WORDS)

Decerebrate rigidity with preserved cognition and gait: a possible role of anoxic-ischemic brain damage

A case of stable decerebrate posture in the upper limbs following sudden loss of consciousness and prolonged coma is described. The patient recovered most of her cognitive functions and gait, without clinical, neurophysiological or neuroradiological evidence of brainstem lesion. MRI shows borderzone infarcts. It is suggested that anoxic-ischemic cortical damage, affecting specially corticoreticular neurons, could explain the development of decerebrate rigidity in patients without apparent brainstem lesion.

Hypothalamic-midbrain dysregulation syndrome: hypertension, hyperthermia, hyperventilation, and decerebration

Certain decerebrate lesions of brain stem or hypothalamus induce pharmacologically reversible hypertension and hyperthermia in animals. We observed three young patients with episodic decerebration, hyperthermia, hypertension, and hyperventilation during recovery from comas of different etiologies. The shared pathology on neurologic examinations and computed tomographic scans was hypothalamic-mesencephalic dysfunction, suggesting a diencephalic-brain-stem disconnection syndrome or brain-stem release mechanism. Propranolol was the most effective drug tested, but only two patients responded, one dramatically. This novel clinical syndrome may have localizing and therapeutic significance in pediatric coma that needs to be further defined in future studies.

Improved outcome prediction based on CSF extrapolated creatine kinase BB isoenzyme activity and other risk factors in severe head injury

The present study of 43 patients with severe head injury shows that outcome prediction can be markedly improved by combining an appropriate marker of the degree of initial brain damage and other risk factors. The patients were classified into three groups according to their actual outcome after 6 months: death (22 patients); persistent vegetative state or severe disability (eight patients); and moderate disability or good recovery (13 patients). By applying stepwise logistic discriminant analysis to the patients' data, five significant risk factors were selected: degree of neurological damage assessed by cerebrospinal fluid (CSF) extrapolated creatine kinase BB isoenzyme activity, Glasgow-Liège Coma Scale score, age, incidence of thoracic injury, and intracranial pressure (ICP). Extrapolated creatine kinase BB activity had the highest prognostic ability (67%). Uncontrollable elevated ICP proved to be systematically associated with death, whereas its absence was not necessarily indicative of a favorable outcome. The combination of the five variables yielded a total prognostic efficiency of 91%. The percentages of correctly predicted patients for the three outcome groups were, respectively, 100%, 50%, and 100%. Thus, half of the persistently vegetative and severely disabled patients were identified by the selected factors.

Variables affecting outcome from severe brain injury in children

This study evaluates the outcome of 56 severely brain injured children (mean age 6.2 +/- 2.1 years) and relates the Initial Glasgow Coma Scale (IGCS), initial intracranial pressure (ICP int), maximal intracranial pressure (ICP max) and minimal cerebral perfusion pressure (CPP min) to quality of survival. Forty-one children sustained head trauma, five severe central nervous system infections and 10 were of miscellaneous etiology. Therapy consisted of mechanical hyperventilation, moderate fluid restriction, dexamethasone and diagnosis specific measures when indicated. Outcome was categorized according to the Glasgow outcome scale at discharge from the hospital. An IGCS of 3 was associated with 100% mortality, 7 and above resulted in 72% good recovery, 28% poor outcome and no mortality. ICP int of less than 20 torr was noted in (67%) of the patients, and did not correlate with ICP max or outcome. Conversely, ICP int in excess of 40 torr correlated well with ICP max and outcome. ICP max of less than 20 torr resulted in 57% good recovery, 36% poor outcome and 7% mortality. ICP max greater than 40 torr resulted in 7% poor outcome and 93% mortality (p less than 0.001). In head trauma, 32 patients (78%) were alive with mean ICP max 16.9 +/- 3.1 and CPP min 65.5 +/- 8.5 torr compared to 9 patients (22%) who died with mean ICP max 53.7 +/- 10.8 and CPP min 6 +/- 3.9 torr, (p less than 0.01). In children with infectious etiology 60% survived with mean ICP max 16 +/- 3 and CPP min 96 +/- 16 torr.(ABSTRACT TRUNCATED AT 250 WORDS)

The Glasgow-Liège Scale. Prognostic value and evolution of motor response and brain stem reflexes after severe head injury

In 1982, we developed a new coma scale, the Glasgow-Liège Scale (GLS), which combines the Glasgow coma scale (GCS) with the quantified analysis of five brain stem reflexes. After severe head injury, the two most important parameters for determining the degree of encephalic disturbances are motor responses (M) and brain stem reflexes (R). The object of this study was to further evaluate the prognosis ability of M and R on admission and during the first month after injury. The study is based on 141 patients. The highest score, during the first day, was less than or equal to 7 on the GCS and 12 on the GLS. Using a multiple group logistic discriminant analysis, we confirmed that, in the first 24 hours, the study of brain stem reflexes appears to be the one factor with the best prognostic ability. We also showed that the prognostic value of certain signs is optimal for a limited period. If, within the two variables M and R, recovery follows an identical pattern whatever the final outcome may be, the restructing speed differs for each outcome. M follows an exponential curve spread over a long period explaining its importance in the course of time. On the other hand, R follows a linear model with straight lines more or less parallel for each outcome. R evolves over a short period of time. These clinical findings give us the opportunity to discuss the physio-pathology of head injury.

Amelioration of hypoxemia by neuromuscular blockade following brain injury

Brain injury has been commonly associated with respiratory failure and uncontrolled skeletal muscle activity. In the present study, neuromuscular (NM) blockade induced by injection of succinylcholine hydrochloride was used to block uncontrolled muscle contractions in dogs with brain injury caused by rapid elevation of intracranial pressure (ICP). Decerebrate posturing, a decrease in value (mean +/- SEM) of arterial oxygen tension (Pa02) of 26 +/- 1 torr, and an increase in arterial carbon dioxide tension (PaCO2) of 11 +/- 1 torr occurred in the dogs, which were supported by mechanical ventilation. The arterial hypoxemia developed independently of the decerebration; however, dogs that demonstrated decerebrate posturing exhibited significantly larger decreases in Pa02 than dogs that did not (P less than 0.01). NM blockade ameliorated the effects of elevated ICP on the arterial blood gases; i.e., the amount of hypoxemia in decerebrate dogs was significantly less in dogs subjected to NM blockade than in dogs not subjected to NM blockade. It is concluded that uncontrolled skeletal muscle activity that exacerbates arterial hypoxemia associated with brain injury is ameliorated by use of NM blockade as a therapeutic adjunct to mechanical ventilation.

Derivation of a bioclinical prognostic index in severe head injury

We investigated the problem of outcome prediction from seven risk factors in 40 severely head injured patients - 13 favorable and 27 unfavorable outcomes. By applying stepwise logistic discriminant analysis to the patients' data, we selected three significant risk variables: cerebrospinal fluid (CSF) CK-BB isoenzyme activity recorded on admission, severely raised intracranial pressure (more than 40 mmHg) and age, respectively. CSF CK-BB activity, which quantifies the initial neurological damage, proved to be the best prognostic factor. The presence of severe intracranial hypertension was always associated with a bad outcome, whereas its absence was not necessarily indicative of good prognosis. Finally, we combined the three selected variables into a single risk index, which allowed correct predictions in 92% of patients with favorable outcome and in 85% of patients with unfavorable outcome (total predictive efficiency 88%).

Bilateral decerebration in head-injury patients. An analysis of sixty-two cases

The factors that contributed to recovery were reviewed in 62 head-injured patients with bilateral decerebration. The most important prognostic variables were age, mode of accident, time interval since injury, results of initial neurological evaluations, and the type of intracranial mass lesion. A higher survival rate was recorded in patients less than 20 years of age, those involved in nonvehicular accidents, those admitted within 6 hours of the accident, and where the vestibuloocular reflexes were preserved. Patients with extradural hematomas and those with nonsurgical intracerebral mass lesions also had a relatively better prognosis. In no patient was elective ventilation, steroid, or megadose barbiturate therapy utilized. Twenty patients (32%) of the 62 survived, and 11 patients had a good functional recovery.

Influence of stimulus location and limb position on motor responses in the comatose patient

Motor responses to standardized stimuli were evaluated in 18 comatose patients with abnormal motor reactions. Painful stimuli were applied to three areas: the supraorbital, sternal, and medial aspects of the arm. Stimulations were carried out with the upper limbs first flexed and then extended. The initial position of the arm significantly influenced the posturing pattern. With the arm initially flexed there was a significantly higher percentage of abnormal flexor reactions, and the opposite occurred with the arm initially extended. Supraorbital stimulation yielded a significantly higher number of extensor responses. Arm stimulation, instead, caused a higher percentage of abnormal flexor reactions. When painful stimulation was applied to an arm initially flexed, the percentage of extensor responses was extremely low. Conversely, supraorbital stimulation with the arms extended yielded the highest percentage of extensor responses. The study shows that, within the frame of abnormal motor responses, the same patient can exhibit different reactions according to the site of stimulation and initial position of the upper extremities. These patterns are fairly constant and should be borne in mind in the evaluation of comatose patients.

Review of 1,000 consecutive cases of severe head injury treated before the advent of CT scanning

This is a review of 1,000 consecutive cases of severe head injury admitted to our Neurosurgical Department between January 1973 and August 1976, before the advent of CT scanning. All patients were comatose following head injury (GCS less than or equal to 8) and were treated homogeneously by the same neurosurgical team by a protocol that included immediate resuscitation on arrival, diagnosis of intracranial lesions by angiography, early surgery when needed, mechanical ventilation, steroids, and mannitol. Extracranial lesions, even if preponderant, were treated by various specialists in the Neurosurgical Department, which for all practical purposes operated as an Emergency Department. Admission criteria were very broad with no preadmission selection. The overall mortality for this series was 45%. A little less than half the patients made good recoveries or remained moderately disabled (47%); 6% were severely disabled, and 2% survived in a persistent vegetative state. More than two-thirds of the patients were brought to our Neurosurgical Department after a short stay at a general hospital; 72% were admitted within 6 hours of injury; 71% were traffic accident victims; and 34% had significant associated extracranial injuries. Carotid angiography was performed in 78% of the patients and indicated the presence of an intracranial haematoma requiring surgery in 36% of the whole series. Mortality was significantly higher in operated than in unoperated patients (56% versus 39%); those treated surgically, however, were older, in worse clinical condition, and showed a higher incidence of acute subdural haematomas associated with brain contusion. Carotid angiography proved very effective in revealing the presence of an expansive lesion but failed to reflect the severity of brain damage, since the group with "negative" angiograms showed a high mortality (52%). Patients with a lucid interval had a higher percentage of surgical lesions than those with immediate coma (58% versus 26%); but fully 42% of them did not require surgery, and 25% had negative angiograms. From the prognostic point of view the clinical data elicited after initial resuscitation were highly predictive of the outcome: some individual neurological signs, such as mydriasis, posturing and eye movements, were not inferior to the GCS score in that respect. Age also proved a strong predictor, since elderly patients are more likely to have severe subdural and parenchymal lesions and their clinical severity is accordingly greater.(ABSTRACT TRUNCATED AT 400 WORDS)

"Locked-in" state following Reye's syndrome

A 12-year-old boy with Reye's syndrome had an initial course complicated by increased intracranial pressure and systemic hypotension. He subsequently developed brainstem damage producing permanent apnea and a "locked-in" state. Nevertheless, the normal architecture of sleep was retained, as was a high degree of intelligence.

Cognitive outcome and early indices of severity of head injury

Neuropsychological outcome of 100 patients with severe head injuries is correlated with their clinical condition on admission. The aim of this paper is to estimate the reliability of several early indices of brain damage severity in formulating a prognosis. Both the Glasgow Coma Scale and the neurological syndrome involved appeared to be highly reliable in this respect. The duration of coma and of posttraumatic amnesia was not as significant. Since these two parameters were assessed when reviewing the cases, they have to be considered only as retrospective judgments. The findings emphasized the importance of reflex ocular motility and the value of recording electroencephalographic (EEG) activity, particularly EEG sleep patterns. The relationship between rapid eye movement sleep impairment and cognitive defects was highly significant. Analysis of surgical observations demonstrated that purely compressive expanding lesions were not as harmful as parenchymal damage. Of paramount importance was the time lapse between injury and surgery, since secondary lesions may develop and affect cerebral areas that are involved both in sleep organization and in memory functions.

Severe head injury managed without intracranial pressure monitoring

A prospective series of 100 consecutive severe head injuries is presented. There were 34 deaths. Intracranial pressure (ICP) was not monitored in this series, and it is suggested that the outcome compares favorably with series in which ICP monitoring was performed. Early evacuation of life-threatening intracranial hematoma and airway control remain essentials of treatment of severe head injury.

Traumatic primary brain stem haemorrhage. A clinical and experimental study

We report 36 cases of post-traumatic "primary brain stem haemorrhage" visualized by the CT scan and confirmed at autopsy. Clinical experience shows that many technical factors influence the inability to visualize brain stem haemorrhages. Experimental injection of fresh blood into the pons and midbrain of cadavers shows that lesions as small as 0.25 ml in volume may be visualized. The volume and the anatomical configuration of traumatic lesions of the brain stem extended over a rostro-caudal direction, and their proximity to bony structures at the base of the skull are obstacles to the visualization of brain stem haemorrhages.

Reversible brain-stem dysfunction following acute traumatic subdural hematoma: a clinical and electrophysiological study

Of 366 consecutive patients with severe head injury, treated and managed by a uniform protocol, 61 (17%) were admitted with signs of severe brain-stem dysfunction. Forty-three of the 61 patients (70%) had surgical mass lesions and 30% had diffuse brain damage. Twelve of the 61 patients (20%) survived, but only six patients made a good to moderately disabled recovery. All six of these patients had a traumatic acute subdural hematoma (SDH). The records of the 20 comatose patients with an acute SDH and severe brain-stem dysfunction were reviewed to discover which factors contributed to functional recovery. The average survivor was operated on within 2 1/2 hours after injury and the nonsurvivors within 4 1/2 hours. Prompt surgical intervention and prudent control of postoperative intracranial pressure were major factors in preventing permanent brain-stem damage, with a significance of p less than 0.05 and p less than 0.02, respectively. Measurement of multimodality evoked potentials in the early postoperative period correctly distinguished between reversible and irreversible brain-stem dysfunction in six of the seven patients.

Traumatic acute subdural hematoma: major mortality reduction in comatose patients treated within four hours

To discover which factors contributed to recovery after surgical intracranial decompression, we reviewed the records of 82 consecutive comatose patients with traumatic acute subdural hematoma (ASDH) who were treated in a single center under a uniform protocol. The delay from injury to operation was the factor of greatest therapeutic importance. Patients who underwent surgery within the first four hours had a 30 per cent mortality rate, as compared with 90 percent in those who had surgery after four hours (P less than 0.0001). Other important prognostic variables included results of the initial neurologic examination, sex, multimodality-evoked potentials, and postoperative intracranial pressure (ICP). If all patients with traumatic ASDH were taken directly to hospitals equipped to diagnose and remove the hematoma within four hours of injury, mortality rates could be reduced considerably.

Noninvasive localization of brain-stem lesions in the cat with multimodality evoked potentials: correlation with human head-injury data

Multimodality evoked potential (MEP) data from over 300 comatose head-injured patients suggest that central nervous system dysfunction of the brain stem and/or hemispheres can be localized with this noninvasive neuroelectric technique. Based on this work, decerebrate motor posturing and prolonged coma are not associated with brain-stem dysfunction but rather with dysfunction of the hemispheres, while absent pupillary and oculocephalic responses are correlated with brain-stem dysfunction alone. However, the accuracy with which MEP data localized human brain-stem or hemispheric dysfunction could not be confirmed by pathological correlation because of low mortality and the small number of autopsies obtained in the patients who died. Therefore, this study was undertaken in an animal model of brain-stem lesion. Complete brain-stem transections were made at the cervicomedullary junction, the medulla just caudal to the eighth nerve, and at the intercollicular region. All cortical visual evoked potential (VEP) peaks were reduced in amplitude and delayed by each of the brain stem transections, but none of the peaks was abolished. In spite of brain-stem transection, VEP's can be used to gain information about hemispheric function. Somatosensory (SEP) and auditory cortically generated evoked potentials (AEP) were abolished by these brain-stem transections, but early-latency brain-stem SEP and AEP data could accurately localize specific areas of brain-stem dysfunction caused by the lesions. Observations made on human MEP data seen to be confirmed by these animal experiments. Correlations between human and cat MEP data are discussed.