Long term results in the management of craniopharyngiomas.

The results of surgical treatment, with and without radiotherapy, in 50 patients with craniopharyngioma treated over a 26-year period at the Cleveland Clinic are presented. Thirty-five patients were operated upon before the introduction of the operating microscope, and 30 of these survived operation. In this group of 30 patients, long term survival (5 to 24 years) occurred in 8 of 10 (80%) nonradiated patients who were considered to have had total excision. Nine of 11 patients (82%) who had aggressive subtotal excision and radiation therapy have survived from 3 to 17 years. Seven of nine patients (78%) died 1 to 14 years after subtotal excision without radiation therapy. Since the introduction of the operating microscope in 1972, 15 patients have had surgical treatment, and 12 of these have survived.

Medical surveillance of animal handlers.

Medical surveillance, with well-documented procedures and benefits, is well-established in general industry. The same cannot be said in the field of animal handling. This chapter presents general principles of and reasons for medical surveillance and explores past practices and current thought related to animal handler surveillance.

Osteomyelitis of the cervical spine: reversible quadraplegia resulting from Philadelphia collar placement.

Pyogenic osteomyelitis of the vertebrae accounts for 4% of all osteomyelitis, and is believed to be increasing in incidence. Pyogenic osteomyelitis of the cervical spine is even more uncommon, accounting for 10% of all spinal pyogenic osteomyelitis. Presented is a case of pyogenic osteomyelitis of the cervical spine in which appropriate methods of immobilization of the cervical spine resulted in a surgically reversible acute deterioration of the patient's neurologic status. While immobilization of the cervical spine remains the initial treatment of choice in most patients with suspected disease of the cervical spine, it is not without potential complications.

IQ levels following trauma.

One hundred fifteen consecutive trauma patients who experienced a head injury and were administered a Wechsler Intelligence Scale as outpatients were selected for study from the Neuropsychology Registry. These patients ranged in age from 4 to 61 years. At the time of examination, all were living at home with their families. Dividing this group of patients on the basis of a Glasgow Coma Score (GCS) of 10 revealed significant differences in group mean post-traumatic IQs. The more severely injured group of patients had a mean post-traumatic IQ of 93.6; the less severely injured patients had a mean IQ of 103.5. The difference between these two groups is significant (p less than 0.005). When divided on the basis of a GCS of 13, the more severely injured group of patients had a mean post-traumatic IQ of 94.2 and the less severely injured group of patients had a mean post-traumatic IQ of 104.2. The difference between these two groups is also statistically significant (p less than 0.0005). There was no statistically significant (p greater than 0.05) difference in the mean post-traumatic IQs of these patients divided on the basis of an Injury Severity Score (ISS) of 15. However, there was a significant difference (p less than 0.05) when the patients were divided at ISS of 17. The less severely injured patients had a mean post-traumatic IQ of 101.2 and the more severely injured patients had a mean post-traumatic IQ of 95.8. The difference between these two groups is statistically significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Behavioral consequences of trauma.

A group of 65 head-injured patients, making an apparent good recovery, were studied with the Halstead-Reitan neuropsychological test battery because of personality or cognitive difficulty. A significant relationship was identified between outcome as measured by the Halstead Impairment Index and both Injury Severity Score and Glasgow Coma Scale score. A significant relationship was also found to exist between the Halstead Impairment Index and employment status of the study group. Patients were placed in three groups, depending on their impairment index. Of the complications identified, spinal fracture, pupillary dysfunction, and intracranial pressure elevation were consistently associated with an impaired performance on the neuropsychological testing. These findings suggest that there is a relationship between head injury complications and neuropsychological potential which can cause lingering problems and influence the patient's rehabilitation process.

Emergency craniotomy in a rural Level III trauma center.

Patients with closed head injury and expanding epidural (EDH) or subdural (SDH) hematoma require urgent craniotomy for decompression and control of hemorrhage. In remote areas where neurosurgeons are not available, trauma surgeons may occasionally need to intervene to avert progressive neurologic injury and death. In 1990, a young man with rapidly deteriorating neurologic signs underwent emergency burr hole decompression of a combined EDH/SDH at our hospital, with complete recovery. In anticipation of future need, five surgeons at our rural, American College of Surgeons-verified Level III trauma center participated in a neurosurgeon-directed course in emergency craniotomy. Since January 1, 1991, 792 patients have been entered into the trauma registry, including 60 with closed head injury and Glasgow Coma Scale (GCS) score of 13 or less. All but seven were transferred to a regional Level II trauma center, which is a minimum flight time of 1 hour each way. All patients with EDH (5) and 2 of 14 with SDH were deemed too unstable for transport and underwent burr hole decompression followed by immediate transfer. All craniotomies were approved by the consulting neurosurgeon and were done for computed tomography-confirmed lesions combined with neurologic deterioration as demonstrated by (1) GCS score of 8 or less, (2) lateralizing signs (dilated pupil, hemiparesis), or (3) development of combined bradycardia and hypertension. One patient with a GCS score of 3 on arrival died. Seven survivors (mean follow-up, 3.9 years; range, 1-6.5 years), including the index case, function independently, although one survivor has moderate cognitive and motor impairment. We conclude that early craniotomy for expanding epidural and subdural hematomas by properly trained surgeons may save lives and reduce morbidity in properly selected cases when timely access to a neurosurgeon is not possible.

Psychological consequences of blunt head trauma and relation to other indices of severity of injury.

To investigate the relationship between APACHE II, Injury Severity Score (ISS), Glasgow Coma Score (GCS), and behavioral outcome, a group of 39 patients who had been admitted on an emergency basis with a traumatic head injury were selected from the Neuropsychology Registry for study. Except for subtle personality and cognitive changes, all of the patients were making good neurological recoveries. The Halstead-Reitan Neuropsychological Test Battery, which has been shown to be accurate in identifying brain-damaged patients, was used as the measure of outcome. The age of the patients ranged from 16 to 49 years (mean, 25.6; SD, 9.3). The patients' educational levels ranged from elementary school to college (mean, 11.6 years of education; SD, 1.5). Halstead Impairment Indexes (HII) ranged from 0.0 to 1.0 (mean, 0.6; SD, 0.26). APACHE II scores were calculated using the worst values, obtained during the first 24 hours. These scores ranged from 5 to 35 (mean, 16; SD, 7). APACHE II was found to not significantly correlate with HII (r = 0.21, P greater than .05). ISS was calculated for each patient and ranged from 5 to 70 (mean, 27; SD, 13). ISS was found to significantly correlate with HII (r = 0.38, P less than .01). GCS ranged from 3 to 15 (mean, 9.3; SD, 3.4). Of all the correlations, GCS was the most strongly correlated with outcome as measured by the HII (r = -0.44, P less than .01). Our data emphasize that head-injured patients have subtle cognitive dysfunction even when apparently recovering well and demonstrate the need for formal psychological evaluation in all patients with injury significant enough to warrant hospitalization.