Transient oculomotor paralysis in pseudotumor cerebri.

Transient oculomotor paralysis developed abruptly in a patient with well-documented pseudotumor cerebri. Other demonstrable causes of third-nerve palsy were excluded. Sixth-nerve palsy is known to occur in 10 to 40% of patients in most series of pseudotumor cerebri, but third-nerve palsy has not been reported previously. It may also be a nonspecific sign of raised intracranial pressure.

Medical complications of head injury.

There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.

Medical technology assessment 1985.

Medical technology, defined broadly as the practical application of medical knowledge, is not always used effectively and efficiently because of imperfect prior assessment. Because of the scientific and financial implications of such inadequate technology assessment, many groups in the executive and congressional branches of the federal government, physician-sponsored organizations, nonphysician professional organizations, and organizations in the private sector have begun investigations of old and new technologies. After a description of these organizations and their activities, the problems of how to evaluate their impact and how to coordinate their work and avoid duplication and discussed. The needs for a neutral national oversight body, for broad societal input into decision making, and for a larger effort in technology assessment are emphasized.

The principles of bony spinal fusion.

Bony fusion is frequently required for anatomical reconstruction and stabilization of the spine. This review discusses bone structure, healing after fracture, and bony fusion, including the use of autografts and allografts. Research should be done on preparation of the bed, the nature and quantity of bone to be used, and how best to immobilize the spine.

New head-positioning system for use with computed tomographic scanning.

A new head-positioning system has been developed to hold the head firmly during the performance of a computed tomograhic scan and to position the head reproducibly during repeat scans. This can be used to maintain the head in position during long scanning sessions, to relate a lesion to landmarks on scout views, to follow lesions in repeated scans over time, and to perform a variety of invasive procedures.

Byron Stookey: "the old lion"--an unsung giant of neurosurgery.

BYRON POLK STOOKEY, an outstanding clinician and teacher, served as Director and Chief of Neurosurgery at the Neurological Institute of New York Columbia-Presbyterian Medical Center. Highlights of his clinical contributions include improved peripheral nerve and spine surgery and subtemporal trigeminal nerve section for tic douloureux. Through diverse activities in both the political and academic arenas of patient care, education, and research, stookey helped to build and strengthen neurosurgery between the world wars and helped to prepare the foundation for the accomplishments of recent decades.

Cerebral herniation from ventricular dilatation after craniectomy: a method of treatment.

Local cerebral herniation due to ventricular dilatation was observed in a patient who had had removal of a bone flap and whose dura had previously been left open. The explanation of this problem was suggested by experimental and clinical evidence relating the development of ventricular enlargement to loss of support of the brain. Such an explanation also suggested that head wrapping to buttress the brain and promote transependymal absorption of cerebrospinal fluid could reverse the condition. This treatment was employed with apparent success.

Brain death.

Brain death is a condition widely recognized by philosophers, theologians, the public, and the law. Criteria for the determination of brain death have been progressively refined for almost 30 years. They involve clinical evidence of the loss of brain function and various periods of observation, which can often be shortened by confirmatory tests, particularly cerebral blood flow studies or electroencephalography. Prompt declaration of brain death is therefore possible. In addition, it is important for physicians to offer the possibility of organ donation to the patient's family both because organs are desperately needed and because many families desire this. A model algorithm for the determination of brain death, explanatory text, and appropriate references are presented to aid the development of protocols for individual and hospital use.

Intracerebral hematoma related to thrombolysis for myocardial infarction.

The incidence of intracerebral hematomas after myocardial infarction increases after thrombolysis. As noted in the case described, clots formed after the administration of thrombolytic agents may remain liquid, and this blood can be drained by a catheter. However, in this case, the patient continued to bleed locally. This problem requires the development of methods to stop such ongoing local bleeding. It may be prevented in the future by improved thrombolytic drugs.

Fracture of the occipital condyle.

Fracture of the occipital condyle is a rare problem. Diagnosis requires a high index of suspicion in a patient with a head injury and abnormalities of function of the lower cranial nerves. The diagnosis is best made by high resolution computed tomographic scanning with sagittal and coronal reconstructions. Although transoral and lateral surgical approaches for decompression and stabilization are possible, these are difficult and frought with danger. We report a case of occipital condyle fracture in which operation was deferred and spontaneous recovery occurred, as has happened in previous cases.

Efficacy and safety of tissue plasminogen activator.

Simple aspiration to remove acute intracerebral hematomas has been thwarted by the solidity of the clot. Urokinase, a first generation fibrinolytic agent, has been used to liquefy such clots with some success. Therefore, tissue plasminogen activator (t-PA), a second generation fibrinolytic drug that may be safer and more effective, was studied to evaluate its ability to lyse clot in vitro and its reactivity in the brain and subarachnoid space. t-PA seems to cause partial clot lysis in small dosages (3750 units/70-cc clot) and in a short time (15 minutes). It seems to perfuse through the clot when injected in one place. It does not cause inflammation or bleeding when injected into the rat brain, but indeed seems to promote resorption of blood when the two are injected together. It does not cause aseptic meningitis when injected into the cisterna magna of rabbits. t-PA may prove to be an important adjuvant to the stereotactic aspiration of intracerebral hematomas. It may be particularly helpful in lysing these clots to make possible more gentle aspiration, removing the risk to surrounding brain of strong vacuum.

Calculation of stereotactic coordinates from the computed tomographic scan.

A protocol has been developed to use the GE 8800 scanner and its resident programs to calculate stereotactic coordinates, which has made it possible to use any stereotactic apparatus without modifying the apparatus in order to introduce a cannula into any lesion visualized on a computed tomographic (CT) scan to biopsy tumors, drain abscesses, implant radioisotopes, etc. The CT scanning is done in a routine fashion except that a lateral ScoutView, with the planes of each CT slice indicated, is included. Once the CT scan has been completed, resident programs for measuring distances are used to establish a zero point on a reference plane, from which all other coordinates can be defined. The stereotactic procedure is done at a separate time in the operating room, using the coordinates derived from the CT scan. The ScoutView image is compared to the lateral x-ray film taken during the stereotactic procedure to establish the location of the targets. It has been estimated that the accuracy of this system is 3 mm. Abscesses less than 1 cm in diameter deep within the cerebral hemisphere have been accurately aspirated and tumor biopsies have been successfully taken.

Cerebrospinal fluid eosinophilia and sterile shunt malfunction.

Cerebrospinal fluid (CSF) eosinophilia is a rare finding most often associated with central nervous system inflammatory processes, including parasitic, bacterial, and mycotic infections. It has also been seen as an allergic phenomenon. We present two cases of CSF eosinophilia occurring concurrently with sterile shunt malfunction. We speculate that CSF eosinophilia in our patients might have resulted from an allergic response to a foreign material such as suture, surgical glove powder, hair, cotton fibers, antibiotics, or silicone rubber. The incidence of sterile CSF eosinophilia after shunting is not known. Information concerning the role of eosinophilia in the development of shunt malfunctions is also lacking. An increased awareness of this possibility and further investigation are warranted.

Detection of brain death in barbiturate coma: the dilemma of an intracranial pulse.

Patients treated with barbiturate coma for elevated intracranial pressure after head injury may suffer brain death. Since such patients have an iatrogenically induced absence of neurological function, brain death cannot be diagnosed clinically. Furthermore, as demonstrated by two of our patients, monitoring of intracranial pressure, even in the face of brain death, may show a low intracranial pressure and an intracranial pulse, suggesting the presence of adequate cerebral perfusion pressure and, therefore, brain viability. Under these circumstances, however, significant intracranial blood flow may be absent. Therefore, we suggest that a patient in barbiturate coma should undergo serial blood flow studies, even when the intracranial pressure is low and an intracranial pulse is present, to determine whether brain death has occurred.

Mechanical aspiration of hematomas in an in vitro model.

A modified Nucleotome (Surgical Dynamics, San Leandro, California) was used to aspirate blood clot in an in vitro model of intracerebral hematoma. This machine was successful in removing the clot at a reasonably rapid rate. It aspirates normal rat brain far more slowly. It therefore shows promise for being effective and safe in removing intracerebral hematomas in humans.

"Nautral" canine model of infantile hydrocephalus.

A review of the current knowledge about a variety of aspects of infantile hydrocephalus suggests that one cause of this problem is subarachnoid blood from birth trauma interacting with an anatomically immature cerebrospinal fluid-absorbing system. To test this hypothesis and to create a model that could be used to devise various methods of prophylaxis and therapy, we injected autologous blood into the cisterna magna of puppies, followed the size of their ventricles with serial computerized tomographic (CT) scans, and evaluated the scanning electron microscopic (SEM) appearance of the ventricular walls and subarachnoid space. By injecting blood until the dogs were just at the point of apnea, we obtained a 46% incidence of hydrocephalus with a 13% mortality rate. The amount of blood accepted was variable. The size of the ventricles was followed with CT scans; the time course of hydrocephalus was variable, and in some cases it resolved. SEM revealed significant regional, free cell aggregation and calcification, especially over the base of the brain, which was most marked in the animals that developed hydrocephalus. This suggests a more marked reaction or a lesser ability to clear the subarachnoid blood in those animals, although the reason for this is not clear. Possible uses for this model are suggested.

Delayed intracerebral hematoma due to traumatic aneurysm caused by a shotgun wound: a problem in prophylaxis.

A delayed traumatic intracerebral hematoma was seen in a patient after a shotgun wound to the brain. The cause of the hemorrhage seemed to be a traumatic aneurysm. Both complications are reviewed, and it is suggested that clinical and intracranial pressure monitoring should lead to early diagnosis and may minimize the effects of this problem and that angiography may be appropriate early in the course of patients who have had fragments pass near intracranial vessels.

Kidney donation: needs and possibilities.

The need for cadaver kidney donors far surpasses the present supply. The subject of how to increase the number of donors is extremely complex, involving not only the medical issue of determination of brain death, but also philosophical, religious, legal, political, psychological, and economic considerations and the opinions of leaders and lay groups. It now seems that the physician can rapidly and unequivocally ascertain brain death, that the law not only recognizes this but can facilitate organ retrieval, that adequate numbers of potential donors should be available, and that both the public and physicians generally favor retrieval. Our survey of patients seeking aid in the emergency room revealed that 19% had signed the donor statement on their driving license. Of the neurosurgeons and neurologists who responded to a questionnaire, 74% had requested donation and 37% had obtained permission for organ retrieval. Review of our case material revealed that 60% of individuals with head injuries alone who were hospitalized for over 3 days were suitable donors. Of the 54 kidneys retrieved during a 6-month period, 49 (90%) were transplanted. Because most potential donors come to the attention of neurosurgeons and neurologists and because it seems ethically appropriate for physicians to consider transplantation when death is certain, we suggest that an organized effort be undertaken to develop a liaison with transplantation services to facilitate the process of obtaining adequate numbers of cadaver kidneys.

General metabolism in patients with acute paraplegia and quadriplegia.

This study measured the nutritional status of eight spine-injured patients during their first 10 to 14 days in the hospital. Initial and follow-up nutritional assessment showed that their nutritional status deteriorated at least partly due to an inadequate supply of protein and calories. Infective complications and prolonged respiratory support were common and may have been caused in part by impaired nutrition. This suggests that a prospective study of aggressive nutritional support for patients with spinal cord transection should be initiated to determine whether this acquired malnutrition and its associated complications can be prevented.

Treatment of calcified cephalohematoma.

This is a case report concerning the surgical treatment of a calcified cephalohematoma, which was possibly caused by an intrauterine fetal monitor. This is the first report of this particular entity as a complication of an intrauterine fetal monitor. As far as we can determine, there is no detailed information available about surgical decision making or surgical techniques for removing such lesions. We operated because of the size and persistence of the lesion. We developed a procedure in which we used the bony cap of the cephalohematoma for a cranioplasty, securing it with microplates.