Pierre Maurette

Long-term neuropsychological outcome and loss of social autonomy after traumatic brain injury

OBJECTIVEnTo assess which social activities were still impaired 5 years after a traumatic brain injury (TBI) in adults, and which neuropsychological impairments were associated with this loss of social autonomy.nnnDESIGNnCross-sectional study of 79 patients selected from the follow-up cohort of an epidemiologic survey of 2,116 TBI patients.nnnSETTINGnThe present study was of ambulatory patients seen at hospital or at their homes. The inception cohort was from the trauma center of a university hospital and from a general hospital that is representative of level II trauma centers in Aquitaine, France.nnnPATIENTSnSeventy-nine patients selected from a representative sample of 407 patients who were included in the 5-year follow-up study of the initial cohort (convenience sample).nnnMAIN OUTCOME MEASURESnGlasgow Outcome Scale (GOS) and loss of social autonomy as assessed by the European Brain Injury Societys European Head Injury Evaluation Chart; assessment of neurobehavioral impairments by means of the Neurobehavioral Rating Scale-Revised.nnnRESULTSnUp to 16 patients suffered disability for at least one social skill because of cognitive/behavioral reasons. Seven needed full-time supervision. Performing administrative tasks and financial management, writing letters and calculating, driving, planning the week, and using public transport were the most impaired social abilities. Loss of social autonomy was mainly observed in severely injured patients. Univariate analysis showed that mental fatigability, motor slowing, memory difficulties, and disorders of executive function were associated with low scores on the GOS, unemployment, and difficulties in shopping, using public transport, and performing financial management and administrative tasks.nnnCONCLUSIONnPersistent impairments of executive functions and speed of psychomotor processing are major factors associated with loss of social autonomy and inability to return to work long after TBI in adults. Improving these impairments in concrete social situations represents a major challenge for cognitive rehabilitation.

Disability and handicap 5 years after a head injury: A population-based study☆

A population-based cohort of 407 head trauma patients has been studied since 1986 to estimate the prevalence of long-term disabilities and handicaps by means of a structured questionnaire. Five years later, 6-1 patients were deceased and 36 were lost to follow-up. Prevalence of subjective and behavioral complaints was high whatever the initial head trauma severity. Lethality in severe head injuries was 56%, and half of the survivors remained disabled. In minor and moderate head injured patients, most disabilities were related to extracranial injuries. Taking all disabilities into consideration, each year 24 per 100,000 patients of such a population are likely to suffer from at least one long-lasting disability, including 10 per 100,000 whose disabilities are due to extracranial injuries. Head injuries induce long-lasting handicap in 9 per 100,000 habitants which is severe in 2 per 100,000. These figures point to the need of reinforcing preventive actions and long-term care of these patients.

Posttraumatic disablement: a prospective study of impairment, disability, and handicap.

This study was designed to evaluate both the frequency and the course of impairments, disabilities, and handicaps resulting from trauma. It was conducted in Aquitaine, France, on a sample of 1005 trauma patients (mean ISS, 10.5 +/- 0.3) in which severe trauma (ISS > 25) was rather overrepresented (169 of 1005). A prospective follow-up of disablement according to the WHO classification was based on medical examinations performed 6 and 12 months after the trauma. Of 664 survivors reviewed at 6 months, the findings were cross tabulated with Injury Severity Score (ISS) and age. There was a good relationship between ISS and the mean length of stay in the hospital (r = 0.46; p < 0.001), the duration of rehabilitation, and the time away from work or school. Out of this sample of 1005 patients with rather major injuries, 73% of the survivors suffered from at least one impairment, with a consistently lower frequency in children whatever the severity. At least one disability was encountered in 52.3% of these patients depending on both ISS and age. Handicap was noted in at least 26% of the cases. Between the sixth month and the end of the first year, the minimal handicap regression was 35.8%, whereas the minimal regression of the disability rate was 19.5%. The best improvement was observed essentially in the low ISS categories. Whereas for minor trauma the course of disablement seems to be fixed 1 year after the injury, such is not the case for severe trauma.

Hyperthermie grave liée à un sevrage brutal de baclofène administré de façon continue par voie intrathécale

Resume Le baclofene est indique dans le traitement de la spasticite post-traumatique. Il comporte non seulement des risques de surdosage, mais aussi de sevrage. Nous rapportons ici deux cas dhypertonie severe avec hyperthermie grave (> 42 °C), survenus lors de larret accidentel dune perfusion intrathecale continue de baclofene. Lhypertonie et lhyperthermie ont cede a la reintroduction du baclofene. Elles etaient cependant accompagnees de perturbations graves des fonctions hepatique (cytolyse), hematologique (coagulopathie de consommation), respiratoire et hemodynamique. Ces troubles ont disparu en quelques jours. En consequence, chez des patients qui recoivent du baclofene au long cours, principalement par voie intrarachidienne, il convient de prevenir un syndrome de sevrage et surtout den detecter les premiers signes. La parente avec les autres hyperthermies malignes est discutee.

Névralgie cervico-brachiale chronique traitée par injection péridurale cervicale de corticoïdes. Résultats à long terme

Resume • Objectif : Evaluer lefficacite a long terme dune injection peridurale cervicale de corticoides (IPCC) chez des patients souffrant de nevralgie cervicobrachiale chronique (NCBC). • Type detude : Etude prospective ouverte. • Patients : Une IPCC a ete effectuee chez 29 patients souffrant, depuis plus de 12 mois, dune NCBC non compressive et non chirurgicale, devenue permanente depuis au moins trois mois et rebelle a un traitement medical correctement conduit. • Methode : Un volume croissant de serum physiologique (jusqua 10 mL) etait injecte dans lespace peridural cervical C7-T1 (aiguille 18G), afin de reproduire la radiculalgie du patient. Un volume equivalent de lidocaine a 0,5 %, associee a de lacetonide de triamcinolone (10 mg·mL −1 ) etait ensuite injecte. Leffet antalgique etait apprecie grâce a une echelle visuelle analogique (EVA) qui cotait la douleur par rapport a la valeur 100 mm notee avant lIPCC. • Resultats : Le volume moyen injecte a ete de 6 ± 2 mL. Il a permis dexacerber la douleur chez 26 des 29 patients. Apres trois mois, 83 % des patients signalaient une diminution de leur douleur qui etait alors cotee a 12 mm sur lEVA. Lefficacite therapeutique a persiste au cours du temps (suivi moyen : 48 ± 18 mois). Parallelement, la consommation dantalgiques et danti-inflammatoires a significativement diminue. • Conclusion : Une injection unique de corticoides par voie peridurale cervicale, chez des patients souffrant de NCBC ne relevant pas dune indication chirurgicale, procure une diminution importante de la symptomatologie douloureuse.

Mesure de la gravité en réanimation traumatologique

Resume L « Injury Severity Score(ISS) est la methode habituellement utilisee en traumatologie pour evaluer letat de gravite dun blesse. La validite de cette methode est faible du fait de sa subjectivite. Lobjet du travail est de comparer lefficacite de ce score clinique (ISS) a un index non specifique essentiellement biologique, plus recent et moins subjectif : le « Simplified Acute Physiology Score(SAPS). Cinq cents patients traumatises, hospitalises en service de reanimation durant lannee 1984, sont etudies retrospectivement. Sont exclus les petits blesses uniquement gardes en salle dobservation. LISS est determine par le meme specialiste. Le SAPS est obtenu a partir du bilan biologique fait lors de ladmission. On compare les sensibilites, specificites et indice de Youden pour chaque score. Les surfaces sous chaque courbe ROC sont comparees par le test de Hanley. LISS moyen est de 23,3±9,2. Lindice de Youden est seulement de 0,1 et determine une sensibilite de 57 % et une specificite de 52 %. Le SAPS moyen est de 8,7±4,3. Lindice de Youden de 0,3 determine une sensibilite de 68 % et une specificite de 62 %. La surface sous la courbe ROC du SAPS (0,69±0,02) est significativement differente de celle determinee par lISS (0,56±0,03; p = 0,0001). En reanimation traumatologique, le SAPS semble etre une methode plus fiable et plus precise de mesure de la gravite que lISS.

Variations de la pression intracrânienne chez le traumatisé crânien grave en hémodialyse

Two cases of acute post-traumatic renal failure in severely head injured patients are reported. An increase in intracranial pressure (ICP) was shown up by continuous monitoring during haemodialysis: it was more important during conventional haemodialysis than during continuous arteriovenous haemofiltration. Although this effect is well known experimentally, few cases of continuous ICP pressure monitoring have been reported in head injury patients undergoing haemodialysis. The increase in ICP is explained in the dog as a result of blood-brain differences in urea concentration and osmolality leading to an increase in cerebral spinal fluid volume and cerebral tissue swelling. If dialysis is necessary in these patients, it should be carried out early and progressively, the patients ICP being monitored continuously.

Résultats de la réanimation chez le sujet âgé traumatisé

Resume Lobjet du travail est danalyser les resultats de la reanimation traumatologique chez le sujet âge et de quantifier limportance des differents facteurs de risque qui entrent en jeu dans levolution finale. Au cours des annees 1984 et 1985, 116 patients de 65 ans et plus ont ete etudies consecutivement. Lâge, la gravite du traumatisme (ISS et SAPS), latteinte neurologique (CGS), letat de sante anterieur (ESA), la survie a trois mois et sa qualite caracterisent chaque malade. La mortalite globale a trois mois est de 45,7 %. Lâge est de 71,2±4,6 ans chez les survivants et de 73,5±7,4 ans dans le cas contraire (p = 0,05). LISS moyen est de 19,7±8 et le SAPS moyen de 9,4±3,2. Le risque de deces est multiplie par 3,6 (1,6 a 8,1) pour un ISS superieur a 15. Il est 4,7 fois plus fort (2 a 11,1) pour un SAPS superieur a 9. Le GCS est de 8,8±4,4 chez les patients decedes et de 12,5±2,7 chez les survivants (p = 0,001). Le risque de deces est multiplie par 10,4 (4,2 a 26,2) si le GCS est inferieur ou egal a 8. Le pronostic final peut etre estime selon la formule exponentielle suivante : survie = 1/[1 + exp − (8,7 − 0,07 × âge − 0,07 × ISS − 2,9 × GCS *)] (ou GCS * = 1 si GCS est inferieur a 8 et GCS * = 0 si GCS superieur a 7). LESA ninfluence pas la mortalite. A trois mois, le traumatisme na pas modifie letat de sante de 87 % des survivants. Il est conclu que lâge et la gravite des lesions alourdissent considerablement la mortalite du vieillard traumatise. Cela ne contre-indique pas la reanimation, qui donne dans des delais raisonnables (16±14,6 jours) une survie de qualite. Une atteinte neurologique grave inaccessible au traitement assombrit encore considerablement le pronostic.

Hémorragie intraventriculaire incoercible révélatrice d’une métastase cérébrale d’un mélanome malin

Resume La mise en evidence de taux eleves d’activateur tissulaire du plasminogene (tPA) dans le liquide ventriculaire au cours d’une hemorragie intracerebrale sur metastase d’un melanome permet d’evoquer le role d’une production tumorale de tPA dans la survenue et la gravite des hemorragies cerebrales lors de metastases cerebrales.