Repeat CT or MRI in posttraumatic headache.

Repeat CT or MRI of the brain should be considered in posttraumatic headache. We describe two patients with posttraumatic headache who had negative CT scans on initial presentation. One patient later had bilateral subdural hematomas on CT, and the other had temporal lobe hemorrhage on MRI. We recommend considering repeat CT or MRI for persisting posttraumatic headache and mental status change.

Increased intestinal permeability following blunt and penetrating trauma.

OBJECTIVES: To determine changes in the absorption of lactulose and mannitol in patients undergoing laparotomy following blunt or penetrating trauma and to correlate any changes in permeability with the severity of injury. DESIGN: Nonrandomized study within patient control. PATIENTS: Consecutive patients admitted to the trauma unit following blunt or penetrating trauma with intra-abdominal injuries warranting emergent celiotomy and jejunal access. INTERVENTIONS: Intestinal permeability was measured in 18 patients within 48 hrs post-trauma by the bolus infusion into the jejunum of nonmetabolized probe molecules, lactulose (molecular weight of 342) and mannitol (molecular weight of 182). Because several patients did not tolerate the bolus infusion, a 3-hr continuous infusion of the probe molecules was used in the last eight patients entered into the study. Intestinal permeability was reassessed before discharge or on days 10 to 12. MEASUREMENTS AND MAIN RESULTS: There was a decrease in urinary lactulose excretion and the lactulose/mannitol ratio between the initial posttrauma measurement and the follow-up permeability measurement using both the bolus infusion (lactulose: initial 0.13 +/- 0.032 vs. follow-up 0.047 +/- 0.012 mmol/6 hrs, p < or = .05; lactulose/mannitol: initial 0.067 +/- 0.012 vs. follow-up 0.044 +/- 0.012, p = .11) and the continuous infusion (lactulose: initial 0.044 +/- 0.013 vs. follow-up 0.014 +/- 0.002 mmol/2 hrs, p < or = .05; lactulose/mannitol: initial 0.055 +/- 0.020 vs. follow-up 0.015 +/- 0.007, p < or = .05). Urine excretion of mannitol was not significantly different between posttrauma and follow-up measurements of intestinal permeability, regardless of the technique used to infuse the lactulose and mannitol. Although the decrease in lactulose and the lactulose/mannitol ratio was significant, only one third of the patients had dramatically increased permeability at the initial measure. Abdominal Trauma Index and Injury Severity Score did not correlate with urinary lactulose excretion or the lactulose/mannitol ratio. Patient tolerance of jejunal administration of lactulose and mannitol was better, using a 3-hr continuous infusion of a dilute solution compared with bolus infusion. CONCLUSIONS: Intestinal permeability is increased in the first 48 hrs posttrauma and decreases with recovery. Although one third of the patients had highly increased lactulose/mannitol ratios posttrauma, severity of injury, assessed by common scoring techniques, did not correlate with the degree of permeability. Tolerance to jejunal administration of lactulose and mannitol is improved with a slow infusion of a dilute solution over a 3-hr period compared with bolus administration.

Acute subdural hematoma: nonsurgical management of selected patients.

There is a current trend toward nonsurgical therapy for small, minimally symptomatic acute subdural hematomas (ASDH), but data supporting such a scheme have been lacking. We evaluated 83 patients with minimally symptomatic ASDH (Glasgow Coma Scale scores of 11-15) and found 58 managed nonsurgically (70%) and 25 managed with craniotomy (30%). Patients managed without surgery had a lower incidence of focal neurologic deficits (12% vs. 40%; p < .01), open cisterns (90% vs. 28%; p < .001), and small (< or = 1 cm) ASDHs (92% vs. 62%; p < .001). Ninety-three percent of patients managed nonsurgically had functional recovery compared with 84% of patients with craniotomy. Age and injury Severity Score were significantly associated with patient outcome. Timing of surgery had no association with outcome. Six percent of patients managed nonsurgically developed chronic SDH requiring craniotomy. We conclude that unless the hematoma is causing clinical evidence of intracranial hypertension or significant neurologic dysfunction, there appears to be no advantage in evacuating the clot. Selected patients with ASDH and GCS scores of 11-15 can safely be managed without craniotomy.