Howard H. Kaufman

Disseminated intravascular coagulation fibrinolytic syndrome following head injury in children." Frequency and prognostic implications

Eight-seven consecutive children with head injury were evaluated within two hours of injury by clinical examination, by computed tomographic brain images, and for systemic blood clotting disorders. All were treated by a standard regimen and survival rates calculated according to the initial neurologic abnormalities and pathology of the injury. Patients with the more severe neurologic abnormalities and those with more brain tissue destruction had poorer survival rates. However, 71% of all patients had one or more abnormal clotting tests and 32% had the disseminated intravascular coagulation and fibrinolysis syndrome by laboratory criteria. The mortality was over four times greater in those patients with DIC compared to those with normal clotting values. Our findings indicate that minor hemostatic abnormalities are the rule in head-injured children, that DIC occurs in nearly one-third of cases, and that DIC is associated with a marked increase in the mortality after brain injury: DIC may be a treatable secondary effect of head trauma that could decrease the mortality.

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.

Posterior lumbar apophyseal fractures.

The radiographic findings in 4 patients with fractures of the lumbar vertebral ring apophysis are reported. All patients had a bony ridge or fragment projecting into the spinal canal, usually from the lower border of L4; a defect in the postero-inferior aspect of the vertebral body; and either an anterior extradural impression or complete blockage on the myelogram. Computed tomography was performed on one patient and appears to be helpful in demonstrating bone within the spinal canal. Preoperative diagnosis can facilitate selection of the appropriate surgical approach.

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.

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.

Post-traumatic subdural hygromas: Observations concerning a surgical enigma

SummaryFour per cent (38) of 881 head injured patients developed known subdural hygromas. Their times of onset and course were variable. However, only two large hygromas seemed clinically significant. Hygromas were more frequent when intracranial pressure monitors were placed, possibly due to opening of the arachnoid, particularly if intracranial pressure was low. But, of course, monitors were only inserted in more severely injured patients. The use of Richmond bolts to drain subdural hygromas in a controlled fashion while monitoring intracranial pressure is suggested.

Cervical myelopathy due to dural compression in mucopolysaccharidosis

A patient with an unusual mixed mucopolysaccharidosis developed cervical myelopathy secondary to compression from a thickened dura mater. Extensive preoperative evaluation was carried out to help anticipate possible surgical problems. Decompression was accomplished safely and resulted in improved neurological function. An aggressive approach to patients with metabolic diseases with good prognosis is indicated.

Rapid onset of delayed traumatic intracerebral haematoma with diffuse intravascular coagulation and fibrinolysis

SummaryA delayed traumatic intracerebral haematoma (DTICH) was seen in a patient with a moderately severe head injury and disseminated intravascular coagulation and fibrinolysis (DICF) two hours after she had a normal computerized tomographic (CT) scan of the brain and five and one half hours after she was involved in a motor vehicle pedestrian accident. It is important to consider the diagnosis of DTICH in patients with head injuries who deteriorate clinically, especially if they have DICF.

A new canine model of proximal internal carotid embolism.

A new model of internal carotid artery embolism was developed using autologous clot. The clot was prepared by incubating blood at room temperature for 2 hours to inactivate plasminogen activators and then refrigerating it at 4° C for 22 hours. The purpose of the experiment was to devise a model of the intravascular lesion and not of stroke itself. The dog was chosen as the experimental animal since it has a maxillocarotid artery which permits collateral flow beyond proximal internal carotid artery occlusions. A volume of clot measuring 0.25 to 030 cc was sufficient to occlude the artery for 48 hours in 80% of the animals without causing major strokes. We have used this model to study clot radiolabeling and suggest it may also have application for evaluating thrombolytic drugs.

Embolus radiolabelling in a new canine model.

SummaryEmbolus radiolabelling with131I fibrinogen was studied in a canine model of internal carotid artery embolization. The dog was chosen as the experimental animal because of its maxillocarotid artery which permits collateral flow round the occlusion and helps to prevent strokes. Clot was prepared by incubating blood at room temperature to inactivate plasminogen activators and then refrigerating it to promote clot retraction. Emboli persisting 48 hours were seen in 80% of animals. Major strokes were not seen when 0.25 to 0.30 cm3 were used. Autoradiography and well counting revealed uptake of isotope. The test, when refined, should provide a tool for the investigation of thromboemboli.