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Broich K, Alavi A, Cruz J, Alves W, Gennarelli T. Evidence of "regional hyperemia" in patients with severe closed head injury using single-photon emission computed tomography. J Stroke Cerebrovasc Dis 2010; 4:271-4. [PMID: 26486251 DOI: 10.1016/s1052-3057(10)80106-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Regional cerebral blood flow (rCBF) was assessed in 32 patients with acute/subacute (n = 18) or chronic (n = 14) head injury using single-photon emission computed tomography (SPECT) and (99m)Tc-hexamethylpropylenenamine oxime (HMPAO) (n = 20) or (123)I-IMP (n = 12). Twelve of the 18 patients with acute/subacute head injury were studied with a high-resolution three-head camera and (99m)Tc-HMPAO. Twenty-eight SPECT studies showed regional abnormalities of tracer uptake. In all cases in which computed tomography (CT) and/or magnetic resonance imaging (MRI) (n = 30) were available for comparison, SPECT showed similar or more extensive abnormalities with high agreement on the laterality of the lesions. Particularly in the 18 patients with acute/subacute head injury, SPECT revealed more and larger lesions than the anatomical scans. In 9 of the 12 patients, at least one region with increase in HMPAO uptake reflecting "hyperemia" was detected (mean study time after injury, 6.3 ± 2.7 days). Follow-up SPECT scans in two patients showed decreased tracer uptake in the previous hyperemic regions and encephalomalacia in the anatomical scan. Thus, hyperemia may reflect "luxury perfusion" in early phases of head injury. In three patients with diffuse axonal injury, a generalized reduction in cortical tracer activity, especially in occipital/parietal regions, was observed. The typical finding in chronic head injury was observation of lesions of similar sizes and high agreement in focal abnormalities between SPECT and CT and/or MRI. However, in nine patients with behavioral disturbances, a decrease in the cortical/basal ganglia was detected. Thus, our study confirms the presence of hyperemia in acute/subacute head injury and demonstrates the value of SPECT for assessing functional impairment in these patients.
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Affiliation(s)
- K Broich
- From the Divisions of Nuclear Medicine and Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, U.S.A
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Beaumont A, Fatouros P, Gennarelli T, Corwin F, Marmarou A. Bolus tracer delivery measured by MRI confirms edema without blood-brain barrier permeability in diffuse traumatic brain injury. Acta Neurochir Suppl 2006; 96:171-4. [PMID: 16671449 DOI: 10.1007/3-211-30714-1_38] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Previous studies have shown that edema formation after diffuse traumatic brain injury (TBI) with secondary insult is cytotoxic and not vasogenic. This assumption is based on observations of reduced apparent diffusion coefficient (ADC) and lack of significant accumulation of intravascular tracer in brain tissue. However, ADC reduction does not exclude vasogenic edema, and intravascular tracer can only accumulate when it reaches the tissue and is not perfusion limited. This study aims to confirm tissue delivery of intravascular tracer and lack of BBB opening during a phase of rapid brain swelling after diffuse TBI. METHODS Rats were exposed to either TBI using the impact acceleration model combined with 30 minutes of hypoxia and hypotension, or sham injury. At 2 or 4 hours after injury, ADC and tissue water content were assessed using MRI. Gd-DTPA was given followed by a combination of rapid T2 imaging (60 seconds) and T1 imaging (30 minutes). Signal intensity changes were analyzed to determine a bolus effect (dynamic susceptibility contrast) and longer-term tissue accumulation of Gd-DTPA. RESULTS Mean increase in cortical water content on the left was 0.8% at 2 hours, 2.1% at 4 hours; on the right it was 0.5% at 2 hours and 1.7% at 4 hours (p < 0.05). Mean ADC reduction over 4 hours was 0.04 x 10(-3) mm2/s on the left and 0.06 x 10(-3) mm2/s on the right. Kinetic analysis of signal intensity changes after Gd-DTPA showed no significant difference in inward transfer coefficient (BBB permeability) between sham injury and 2 or 4 hours post-injury. T2 imaging showed consistent tissue delivery of a bolus of Gd-DTPA to the tissue at 2 and 4 hours post-injury, comparable to sham animals. CONCLUSIONS Progressive cerebral edema formation after diffuse TBI occurred during ADC reduction and without continued BBB permeability. Tissue delivery of Gd-DTPA was confirmed, verifying that lack of tracer accumulation is due to an intact BBB and not to limited perfusion.
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Affiliation(s)
- A Beaumont
- Dept of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
BACKGROUND Cerebral contusions have a 51% incidence of evolution in the first hours after injury. Evolution is associated with clinical deterioration and is the reason for ICP monitoring or surgical intervention. We sought to define CT features that predict cerebral contusion evolution. METHODS Patients treated for cerebral contusion who had 2 CT scans within 24 hours after injury were evaluated (n = 21). CT scans were analyzed for area of contusion, hemorrhagic components, and edema. Increase (%) in contusion size was recorded. Contusion evolution was defined as > 5% size increase. Ratios of hemorrhagic components to surrounding edema were calculated. RESULTS Ten patients (47.6%) showed contusion evolution and 11 (52.4%) did not. Age, sex ratio, or injury severity between the 2 groups did not differ. Eight of 10 patients with evolving contusions had minimal or no perilesional edema on first CT; only 2 of 11 nonevolution patients had perilesional edema (p < 0.005). Mean ratio of area of surrounding edema to area of hemorrhagic products on first CT was 0.770 in evolution group versus 2.22 in non-evolution group (p = 0.055). CONCLUSIONS A higher proportion of patients without contusion evolution had perilesional edema present on first CT scan. The absence of pericontusional edema on early CT may be a useful marker to predict contusion evolution.
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Affiliation(s)
- A Beaumont
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Kambin P, Gennarelli T, Hermantin F. Minimally invasive techniques in spinal surgery: current practice. Neurosurg Focus 1998; 4:e8. [PMID: 17206771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Minimally invasive spinal surgery under arthroscopic or endoscopic magnification and illumination is emerging as an alternative, reliable method of treatment in a variety of spinal disorders. The operative techniques being used for discectomy and retrieval of herniated disc fragments or stabilization of unstable spinal motion segments are being utilized for visual diagnosis and debridement of infectious discitis and osteomyelitis transpedicular and transforaminal vertebral body biopsy, temporary diagnostic fixation of unstable lumbar motion segments, and transforaminal epidural steroid therapy.
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Affiliation(s)
- P Kambin
- Departments of Orthopedic Surgery, Neurosurgery, and the Spine Diagnostic and Treatment Center, Allegheny University Hospitals MCP, Philadelphia, Pennsylvania
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Alavi A, Mirot A, Newberg A, Alves W, Gosfield T, Berlin J, Reivich M, Gennarelli T. Fluorine-18-FDG evaluation of crossed cerebellar diaschisis in head injury. J Nucl Med 1997; 38:1717-20. [PMID: 9374339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
UNLABELLED This study investigates the phenomenon of crossed cerebellar diaschisis in head injury patients. METHODS We visually compared fluorine-18-fluorodeoxyglucose (FDG)-PET images to radiograph computed tomography or magnetic resonance images in 19 patients with head injury. RESULTS We found that of 68 focal unilateral lesions, 40% were associated with contralateral cerebellar hypometabolism and 19% were associated with ipsilateral cerebellar hypometabolism. Of supratentorial, extraparenchymal lesions (n = 20), 45% were associated with contralateral cerebellar hypometabolism, whereas 15% had ipsilateral cerebellar hypometabolism. Intraparenchymal lesions were associated with contralateral cerebellar hypometabolism in 38% of the patients and with ipsilateral cerebellar hypometabolism in 21% of the patients. Of the cortical lesions that were the patients' most severe injury, 69% were associated with contralateral cerebellar hypometabolism, whereas only 8% were associated with ipsilateral cerebellar hypometabolism. In patients with focal supratentorial lesions alone, 50% of all focal lesions were associated with contralateral cerebellar hypometabolism and 13% had ipsilateral hypometabolism. Of patients with both focal and diffuse brain injuries, 27% of the focal lesions had contralateral cerebellar hypometabolism and 27% had ipsilateral cerebellar hypometabolism to the most severe focal injury. CONCLUSION Crossed cerebellar diaschisis is seen more often in patients with focal cortical or extraparenchymal injuries and is not seen in patients with multiple or diffuse brain injuries. Furthermore, this predominance is more pronounced with lesions of the greatest severity.
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Affiliation(s)
- A Alavi
- Department of Neurology, University of Pennsylvania, Philadelphia, USA
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Abstract
A three-valued description of anatomic injury is presented. Anatomic profile (AP) components A, B, and C summarize serious injuries (greater than AIS 2) to the head/brain or spinal cord; to the thorax or front of the neck; and all remaining serious injuries. Relationships between AP components and survival rate reaffirm the seriousness of head injury. Logistic function models relating AP components and the Injury Severity Score (ISS) to survival probability were based on 20,946 Major Trauma Outcome Study (MTOS) patients (9.2% mortality rate) submitted through 1986. Model performance comparisons were based on 5,939 MTOS patients (7.8% mortality rate) submitted during 1987. The AP better discriminated survivors from nonsurvivors and provided a 31% increase in sensitivity when compared with the ISS. Neither the ISS nor the AP alone reliably predict patient outcome. The predictive power of methods for estimating patient survival probability which include physiologic indices or profiles, patient age, and an anatomic profile should be compared with current methods. The AP, which is based on the severity and location of all serious injuries, provides a more rational basis for comparing patient samples than the ISS.
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Affiliation(s)
- W S Copes
- Washington Hospital Center, DC 20010
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Tomei G, Spagnoli D, Ducati A, Landi A, Villani R, Fumagalli G, Sala C, Gennarelli T. Morphology and neurophysiology of focal axonal injury experimentally induced in the guinea pig optic nerve. Acta Neuropathol 1990; 80:506-13. [PMID: 2251908 DOI: 10.1007/bf00294611] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A new model of focal axonal injury was reproduced by rapid and controlled elongation (uniaxial stretch) of the guinea pig optic nerve. Light microscopy study of optic nerve specimens after horseradish peroxidase injection into the vitreous of the animal's eye showed that axonal lesions were identical to those seen in human and primate post-traumatic diffuse axonal injury (DAI). The lesions were characterized by the formation of terminal clubs in severed axons and focal axonal enlargements in those axons that were lesioned-in-continuity. Visual-evoked potentials upon flash stimulation were recorded before and after injury. Mean amplitude and mean latency of occipital peaks were significantly elongated in the acute post-traumatic phase. Electron microscopy examination showed that the main axonal changes observed in this model were cytoskeleton disorganization, accumulation of axoplasm membrane-bound bodies at the site of terminal balls and dilatations-in-continuity and detachment of the axolemma from the myelin sheath. Such axonal alterations were similar to those found in many other biological models of central and peripheral axonal injuries in which the lesion was produced by invasive methods. This model is unique since it reproduces the same mechanism of injury and the identical lesions that have been demonstrated in humans and primates with post-traumatic (DAI).
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Affiliation(s)
- G Tomei
- Institute of Neurosurgery, University of Milan, Italy
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Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, Gennarelli T, Mackenzie E, Schwaitzberg S. A new characterization of injury severity. J Trauma 1990; 30:539-45; discussion 545-6. [PMID: 2342136 DOI: 10.1097/00005373-199005000-00003] [Citation(s) in RCA: 303] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
ASCOT (A Severity Characterization of Trauma) is a physiologic and anatomic characterization of injury severity which combines emergency department admission values of Glasgow Coma Scale, systolic blood pressure, respiratory rate, patient age, and AIS-85 anatomic injury scores in a way that obviates ISS shortcomings. ASCOT values are related to survival probability using the logistic function and regression weights reaffirm the importance of head injury and coma to the prediction of patient outcome. The ability of TRISS and ASCOT to discriminate survivors from non-survivors and the reliability of their predictions, as measured by the Hosmer-Lemeshow statistic, were compared using Major Trauma Outcome Study (MTOS) patient data. ASCOT performance matched or exceeded TRISS's for blunt-injured patients and for penetrating-injured patients. ASCOT performance gains were modest for blunt-injured patients. The Hosmer-Lemeshow statistics suggest that ASCOT reliably predicts patient outcome for penetrating-injured patients and nearly so for blunt-injured patients. Statistically reliable predictions were not achieved by TRISS for either set. ASCOT provides a more precise description of patient physiologic status and injury number, location, and severity than TRISS. The ASCOT patient description may be useful in relating to other important outcomes not highly correlated with TRISS or the Injury Severity Score (ISS) such as disability, length of stay, and resources required for treatment.
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Dempsey DT, Guenter P, Mullen JL, Fairman R, Crosby LO, Spielman G, Gennarelli T. Energy expenditure in acute trauma to the head with and without barbiturate therapy. Surg Gynecol Obstet 1985; 160:128-34. [PMID: 3918351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The increased energy expenditure associated with severe trauma to the head appears genuine but exhibits wide variation in its magnitude. Patients with severe acute trauma to the head without barbiturate treatment are hypermetabolic with an average energy expenditure 26 per cent over predicted. Barbiturate therapy abolishes this hypermetabolism and decreases energy expenditure to 14 per cent below predicted. In the individual patient, there appears to be a close relationship between the degree of suppression of energy expenditure and the serum barbiturate level. However, this relationship would appear to be different in each patient, and therefore, for this group, a significant correlation between energy expenditure and serum barbiturate level does not exist. The wide variability of energy expenditure in individual patients makes the estimation of energy expenditure by population predictive formulas imprecise. This may lead to incorrect estimates of caloric requirements and inappropriate provision of exogenous energy substrates. Although for those patients receiving energy expenditure and serum barbiturate levels in the individual may further aid in estimating the caloric expenditure for each individual, in order to provide appropriate amounts of calories to the patient with trauma to the head, energy expenditure should be measured in each instance.
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Abstract
Minor head injury or concussion was produced in experimental animals by an acceleration-deceleration non-impact injury. The animals sustained a brief loss of consciousness and no sequelae were observed. The brains were examined at 7 days by means of the Nauta and Fink-Heimer techniques. Degenerating axons were noted in the inferior colliculus, pons, and dorsolateral medulla. Degeneration was not seen in the subcortical white matter, thus suggesting a primary brain-stem locus for concussion. These findings also suggest that, in some instances, minor head injury or concussion can be associated with organic damage to the central nervous system.
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Harris RI, Schatz NJ, Gennarelli T, Savino PJ, Cobbs WH, Snyder PJ. Follicle-stimulating hormone-secreting pituitary adenomas: correlation of reduction of adenoma size with reduction of hormonal hypersecretion after transsphenoidal surgery. J Clin Endocrinol Metab 1983; 56:1288-93. [PMID: 6404924 DOI: 10.1210/jcem-56-6-1288] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Ten men who had FSH-secreting pituitary adenomas were evaluated before and 4-6 weeks after transsphenoidal surgery to determine whether reduction of adenoma mass would ameliorate the hormonal abnormalities associated with these adenomas. Nine of the 10 men exhibited marked reduction in adenoma size, as judged by computerized tomography, an 7 had improvement in vision. The same 9 men also had decreases in basal serum FSH concentrations to within the normal range after surgery. The 1 man who had no reduction in adenoma size by computed tomographic scan and whose serum FSH concentration did not decrease to normal after surgery was also the only patient whose abnormal FSH and LH responses to TRH did not improve after surgery. Another man, who had a reduction in adenoma size and serum FSH concentration after surgery, subsequently had regrowth of the adenoma and concomitant resurgence of the FSH concentration. Two men had increases in their serum testosterone concentrations from subnormal to well within the normal range after surgery, suggesting that gonadotroph cell adenomas may impair LH secretion from normal gonadotroph cells. We conclude that the correlation of reduction in adenoma size with reduction in hormonal hypersecretion after surgery suggests that the hormonal hypersecretion is a direct consequence of the adenomatous tissue.
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Zimmerman RA, Bilaniuk LT, Gennarelli T, Bruce D, Dolinskas C, Uzzell B. Cranial computed tomography in diagnosis and management of acute head trauma. AJR Am J Roentgenol 1978; 131:27-34. [PMID: 97980 DOI: 10.2214/ajr.131.1.27] [Citation(s) in RCA: 105] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Review of the computed tomographic findings in 286 patients with acute craniocerebral trauma revealed several types of lesions: hemorrhagic contusion, intracerebral and extracerebral hematomas, general and focal cerebral swelling, and shearing injury of the cerebral white matter. Hemorrhagic contusions are the most frequent lesion and may result in focal neurologic deficits. General cerebral swelling occurs frequently in children and necessitates prompt medical management for complete recovery. Mortality rates for intracerebral, subdural, and epidural hematomas were lower for this series than for series that preceded computed tomography. Because of the availability of computed tomography, there was an 84% reduction in arteriography, 58% reduction in surgical intervention, and a 24% reduction in skull radiography.
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Abstract
An acute spinal epidural abscess is reported from which a pure growth of the anaerobe Fusobacterium necrophorum was isolated. The mode of infection and pathogen makes it unique. The literature concerning the bacteriology of epidural abscess and the implications of anaerobic epidural infection are discussed.
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