Severe head injury. Clinical assessment and outcome.

A prospective study of 213 patients with severe head injury and Glasgow Coma Scores of 8 or less was conducted to identify, at 24 hours postinjury, the favorable and unfavorable clinical factors that relate to outcome one year later. According to the Glasgow Outcome Scale, 35 percent were classified Moderate Disability or Good Recovery, 13 percent were classified Severe Disability or Vegetative State, and 52 percent had died. The presence of intact brain-stem reflexes 24 hours postinjury in comatose patients with head injury is a prognostic sign for a good recovery. Favorable clinical signs include eye opening, pupillary reactivity, spontaneous eye movement, intact oculovestibular reflexes, and motor responses such as localizing. A prognosis of poor recovery is associated with nonreactive pupils, absent oculovestibular reflexes, and motor response of extension or no response at all. These negative signs, when present individually, were associated with only a 3 to 4 percent Moderate Disability or Good Recovery rate and an 85 to 91 percent mortality rate. The Glasgow Outcome Scale was also used to define recovery patterns at intervals during the first year after injury. Ninety percent of patients reached their highest outcome category by six months. The most frequent one-month outcome category for survivors was Severe Disability. By six months postinjury, 68 percent of these patients had made sufficient neurological progress to change their classification to Moderate Disability or Good Recovery. The 16 percent of patients classified at one month as in a persistently Vegetative State had a prognosis of poor outcome. Only 28 percent of these patients progressed in one year to the Severe Disability classification.

The utilization of native glioma antigens in the assessment of cellular and humoral immune responses in malignant glioma patients.

Cellular and humoral components of the immune response have been studied preoperatively, concurrently, and serially in patients with malignant glial neoplasms. In order to assess titres of circulating antibodies to tumour cell constituents an indirect immunofluorescent technique was applied to single cell suspensions and snap frozen cell smears. In an allogeneic system, 49% of 47 test and 7% of 124 control sera gave a positive response to cytoplasmic components. The leucocyte adherence inhibition assay was applied to study 39 test and 64 control patients. Significant non-adherence of leukocytes was observed in 77% of test cases. Control parameters indicated specificity of the response. Simultaneous assessment in 28 test patients yielded a positive response for one or both assays in 89% of cases..

Pituitary apoplexy, therapeutic assessment.

The management of pituitary apoplexy with reference to both diagnosis and operative sequelae remains a major challenge. Acute onset of retro-orbital headache in association with visual loss and ophthalmoplegia are the cardinal symptoms; however, obtundation and signs of subarachnoid hemorrhage also may be present. Good quality plain skull radiographs and complete angiography prove sufficient for preoperative radiographic studies. Preoperative endocrine preparation focuses on supplemental glucocorticoids since these patients must be presumed deficient in cortisol reserve. Residual visual deficit appears to be more a function of the extent of damage at the time of ictus rather than rapidity of decompression. Our experience indicates that transsphenoidal decompression in appropriate cases offers an ideal opportunity to minimize mortality and morbidity. The acute onset of severe retro-orbital headache in association with stupor and ocular palsies would alert most physicians to the potential diagnosis of spontaneous subarachnoid hemorrhage. The association of complex ophthalmoplegias and visual defects in this constellation of symptoms should, in addition, alert one to the possibility of an acute intrasellar or parassellar expansile process. During the past two years, we have had the opportunity to care for 8 such patients with confirmed diagnoses of acute hemorrhagic infarction of the pituitary enabling us to formulate diagnostic and therapeutic schemata with reference to management of this problem.