Philip L. Gildenberg

The Incidence and Significance of Hemostatic Abnormalities in Patients with Head Injuries

Abnormal coagulation and fibrinolysis is a frequent complication in patients with head injury. This complication can be severe enough to lead to hemorrhage or thrombosis. A study was undertaken to determine if the hemostatic abnormalities are reliable indicators of outcome. Hemostasis in 269 patients with head injuries alone was screened using platelet count (PC), prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin clotting time (TCT), fibrinogen assay (FIB), level of fibrin-fibrinogen degradation products (FDP), and disseminated intravascular coagulation (DIC) score in the first 24 hours after injury. Test results were compared with the outcome (discharged or dead) in the entire group and in subgroups divided on the basis of the severity of injury as determined by the Glasgow coma score (GCS). Increased consumptive coagulopathy at admission, as reflected in the DIC score, predicts the outcome of head-injured patients with a high degree of accuracy. The degree of increase of the initial FDP level and prolongation of TCT also correlated positively with the outcome. Prolongation of the APTT correlated strongly with unfavorable outcome in a large group of patients, and in a small group, markedly accelerated APTT also predicted death. Stepwise logistic regression analysis demonstrated that GCS, FDP level, and DIC score predicted outcome. Other tests did not provide additional predictive value. Abnormal hemostasis frequently complicates the course of patients with head injuries. This study demonstrates that hemostasis tests are predictors of outcome in these patients.

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.

Gunshot wounds to the head: a perspective

Craniocerebral gunshot wounds are a significant cause of injury and death in the United States. However, despite reports of occasional unexpectedly favorable outcome in surgically treated patients, these injuries have been viewed pessimistically and indeed have generally been excluded from modern studies of head injuries, which have concentrated on closed head injuries. A review of 143 victims of craniocerebral gunshot wounds admitted to Hermann Hospital, Houston, Texas, during a recent 30-month period confirmed that a few apparently neurologically devastated patients can be saved. A detailed analysis of these patients, including demographic details, general and neurological condition, anatomic injuries, laboratory findings, surgical care, neurological course, and neurological and functional outcome follows. The helpfulness of early resuscitation and appropriate criteria for surgery need to be studied using historic or randomized controls.

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.

Pallidotomy: a survey of current practice in North America.

Twenty-eight centers completed a survey about their current practice of pallidotomy. This sample represents a non-exhaustive survey of the current practice of pallidotomy in North America and is not a study of outcomes. 1015 patients underwent 1219 pallidotomies: 811 (80%) unilateral, 72 (7%) staged bilateral, and 132 (13%) simultaneous bilateral. Pallidotomy has long been an accepted procedure and the indications for this surgery, in the opinion of the responding centers, were rated on a scale of 1 (poor) to 4 (excellent) and demonstrated dyskinesia as the best indication (median = 4); on-off fluctuations, dystonia, rigidity, and bradykinesia as good indications (median = 3); and freezing, tremor and gait disturbance as fair indications (median = 2). Most centers used MRI alone (50%) or in combination with CT scan (n = 6) or ventriculopathy (n = 5) to localize the target. The median values of pallidal coordinates were: 2 mm anterior to the midcommissural point 21 mm lateral to the midsagittal plane and 5 mm below the intercommissural line. Microrecording was performed by half of the centers (n = 14) and half of the remaining centers were considering starting it (n = 7). Main criteria used to define the target included the firing pattern of spontaneous neuronal discharges (n = 13) and the response to joint movement (n = 10). Most centers performed motor (n = 26) and visual (n = 23) macrostimulation. Twenty four centers performed test lesions using median values of 55 degrees C temperatures for 30 s. Final lesions consisted of 3 permanent lesions placed 2 mm apart, each lesion created with median values of 75 degrees C temperatures for 1 minute. Median hospital stay was 2 days.

Civilian gunshot wounds: the limits of salvageability

SummaryPatients who have suffered gunshot wounds in civilian settings, who present with posturing and in whom the bullet has passed through the geographical centre of the brain have generally not been felt to be salvageable. However, surprisingly favourable outcomes in two such patients have led us to believe that some such patients may deserve agressive treatment.

Influence of Dorsal Column Stimulation upon Human Thalamic Somatosensory-Evoked Potentials

2 patients with previously implanted dorsal column stimulators underwent basal thalamotomy for the treatment of pain, which provided the opportunity to record evoked potentials from the intralaminar (IL) and ventroposterolateral (VPL) areas of the thalamus. Short latency evoked potentials recorded from VPL were not influenced by dorsal column stimulation. However, very long latency (500 ms) potentials recorded bilaterally in IL were modified by stimulation of the dorsal columns of the spinal cord at frequencies between 20 and 40 HZ.

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.

General metabolism in head injury

Seventy-six patients with closed head injuries alone were studied to define the relation between the severity of the head injury and secondary alterations of general metabolism. The effect of metabolic changes on neurological outcome and the importance of nutritional support on nutritional status and neurological outcome were also evaluated. Using a powerful statistical tool, convergence analysis, it was possible to take into consideration the effects of a number of confounding factors that obviously affected general metabolism. Most of the patients were hypermetabolic for prolonged periods. In addition, many did not receive even basal requirements of calories or protein for many days. Despite this, their outcomes were determined by their initial neurological status and the amounts that they were fed, admittedly relatively modest, did not influence their courses. Despite such feedings, their visceral protein levels, which often dropped initially, rose toward normal levels, indicating effective adaptation. Indeed, it could not be shown that these patients developed complications of malnutrition such as infections. However, it will require a sophisticated randomized clinical trial of vigorous intravenous hyperalimentation to determine whether this complex, dangerous, and expensive therapy is helpful for severely head-injured patients.