Michael E. Miner

Safety and efficacy of a multicenter study using intraarterial chemotherapy in conjunction with osmotic opening of the blood-brain barrier for the treatment of patients with malignant brain tumors.

The aim of this study was to determine the safety and efficacy of intraarterial chemotherapy with osmotic opening of the blood‐brain barrier (BBB) for the treatment of malignant brain tumors when administered across multiple centers.

Behavioral Changes After Closed Head Injury in Children

This study provides a longitudinal follow-up of the behavioral adjustment of 45 children with mild, moderate, and severe closed head injuries. Two measures of behavioral adjustment, the Child Behavior Checklist (CBCL) and the Vineland Adaptive Behavior Scales (VABS), were obtained from a parent at the time of injury and at 6 and 12 months postinjury. The severely injured children obtained significantly poorer VABS scores than children with mild and moderate injuries over the year-long follow-up. In addition, on the CBCL, severely injured children had more school problems and engaged in fewer social activities than mild and moderately injured children. These results show that severe head injury in children was associated with declines in adaptive functioning, whereas scores for children with mild and moderate injuries did not differ, nor did they deviate from average levels at any follow-up interval. Language: en

Delayed and recurrent intracranial hematomas related to disseminated intravascular clotting and fibrinolysis in head injury

Twelve delayed or recurrent intracranial hematomas were seen in 340 patients with head injuries. Eleven of these hematomas were associated with clotting abnormalities suggesting disseminated intravascular clotting and fibrinolysis (DICF). Seven of 8 delayed traumatic intracerebral hematomas were associated with clotting abnormalities. Two of these were at ventriculostomy sites, which suggests an increased risk of bleeding in association with the insertion of ventricular catheters in patients with DICF. There were 2 delayed epidural hematomas, 1 under a fracture and the other on the side opposite a craniotomy that had been made to treat an intracerebral hematoma, and there were 2 postoperative epidural hematomas. No postoperative hematomas occurred in the absence of DICF. DICF is a major factor in the development of delayed and recurrent intracranial hematomas in patients with head injuries.

The Children's Orientation and Amnesia Test: Relationship to Severity of Acute Head Injury and to Recovery of Memory

The Childrens Orientation and Amnesia Test (COAT) was developed to assess cognition serially during the early stage of recovery from traumatic brain injury in children and adolescents. The norms for the COAT, which is composed of 16 items evaluating general orientation, temporal orientation, and memory, were defined from data obtained from 146 children aged 3 to 15 years. In 37 patients with head injuries, the duration of posttraumatic amnesia, as indicated by the number of days COAT scores were in the impaired range, was significantly related to both verbal and nonverbal memory at the baseline and 6 and 12 months after injury. COAT scores were a better predictor of verbal and nonverbal memory performance than the Glasgow Coma Scale score at 6 and 12 months after the injury. This study shows that the COAT has adequate reliability and validity as a measure of the duration of posttraumatic amnesia in children and adolescents.

Attentional Disturbance After Pediatric Closed Head Injury

The influence of severity of closed head injury and age on attentional functioning was prospectively investigated in 36 children (age range, 7 to 16 years) 6 months after injury. Children were placed into mild, moderate, and severe injury groups using established neurologic criteria. Each child received the Wechsler Intelligence Scale for Children-Revised Digit Span subtest and a continuous performance test. Children with severe closed head injury demonstrated significantly poorer continuous performance test scores than mildly or moderately injured children. Injury severity had no effect on Digit Span scores. Younger children exhibited more pronounced impairment on the continuous performance test relative to uninjured age peers. These results extend the persistence of attentional impairments beyond those of previous reports. Closed head injury is not associated with preferential sparing of sustained attention in younger children 6 months after injury. Brain injury earlier in life may result in delayed vulnerability of information processing skills. (J Child Neurol 1993;8:348-353).

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.

Verbal and nonverbal skill discrepancies in hydrocephalic children

This study evaluated a large sample (N = 90) of 5- to 7-year-old children with hydrocephalus caused by aqueductal stenosis or prematurity-intraventricular hemorrhage or associated with spina bifida. Comparison groups of normal controls, children with spina bifida and no shunt, and premature children with no hydrocephalus were also evaluated. Comparison of skill discrepancies at two occasions separated by 1 year revealed that hydrocephalic children, as a group, showed poorer nonverbal than verbal skills on measures from the McCarthy Scales of Childrens Abilities, the WISC-R, and composites of neuropsychological skills. No discrepancies in verbal-nonverbal memory were found nor were any discrepancies attributable to etiology or motor demands of the tasks. Consistent with current hypotheses concerning the role of the cerebral white matter in cognitive development, these results show that hydrocephalic children in this age range generally have poorer development of nonverbal cognitive skills relative to their language development.

Continuous monitoring of cerebral oxygenation in acute brain injury: assessment of cerebral hemodynamic reserve.

A new index of cerebral hemodynamics, cerebral hemodynamic reserve (CHR), was evaluated in 12 comatose adults with severe, acute, traumatic, diffuse swelling of the brain, who underwent continuous monitoring with a fiberoptic catheter of the saturation difference in arteriojugular oxyhemoglobin. CHR

Motor, Visual-Spatial, and Somatosensory Skills After Closed Head Injury in Children and Adolescents: A Study of Change

Correlational studies of recovery of function following traumatic brain injury have revealed weak, nonspecific relationships between outcome and injury variables. In order to better identify factors affecting recovery, 49 children (aged 6-15 years) were followed prospectively with repeated neuropsychological assessment of motor, visual-spatial, and somatosensory skills up to 5 years postinjury. Analyses of individual growth curves revealed systematic nonlinear changes after injury. Variability among growth patterns related robustly to injury variables. Younger children with severe injuries showed slower growth on visual-spatia l and motor tasks than did older children of similar severity or similarly aged children with less severe injuries. These findings support a hypothesis of increased vulnerability of rapidly emerging skills in young children and argue against an explanation of lowered recovery rates due to concomitant maturational influences on development. Results of studies of cognitive functioning in children after closed head injury (CHI) have consistently demonstrated the presence of deficits in motor skills and nonverbal processing during the subacute phase of recovery (Klonoff, Low, & Clark, 1977; Levin & Eisenberg, 1979a, 1979b). These motor and nonverbal deficits persist one or more years postinjury (Chadwick, Rutter, Brown, Shaffer, & Traub, 1981; Knights et al., 1991; Winogron, Knights, & Bawden, 1984). Additional studies have demonstrated deficits in memory (Levin et al., 1988), language (Levin & Eisenberg, 1979a, 1979b), and behavioral adjustment (Fletcher, Ewing-Cobbs, Miner, Levin, & Eisenberg, 1990). Yet, few studies of neurobehavior al function in children after CHI have addressed changes in performance patterns over time or the actual process of change. To study the recovery process, researchers must use longitudinal measurement of specific abilities and behaviors. For instance, Chadwick, Rutter, Brown, Shaffer, and Traub (1981) prospectively studied the recovery of IQ scores in children up to 27 months after CHI. By testing the children

Surgical treatment of the spontaneous spinal epidural abscess

Seven cases of spontaneous epidural abscess are reviewed. Three patients had posterior abscesses and no evidence of vertebral body osteomyelitis. These patients had excellent outcomes with laminectomies and antibiotics. Because of significant vertebral destruction, two patients with vertebral osteomyelitis required posterior fixation after laminectomy. Two other patients with vertebral osteomyelitis had complete destruction of the vertebral body and required anterior decompression and fusion in addition to posterior fixation. In the four patients with vertebral osteomyelitis, morbidity was high, reflecting their age and significant medical problems. This review supports the contention that medically stable patients with posterior epidural abscesses can be treated with laminectomy and antibiotics with little risk of progressive instability. The proper surgical treatment of anterior epidural abscesses secondary to osteomyelitis requires knowledge about the amount of destruction of the supporting columns, the amount of neural compression secondary to the purulence, and the patients general medical condition.