Robert L. McLaurin

Pituitary Hormone Response to Head Injury

Measurements of the serum levels of pituitary hormones were made in six patients with uncomplicated head injury. Samples were obtained at 4-hour intervals for 72 hours to evaluate diurnal rhythms. Three of the six patients revealed elevations of serum growth hormone (GH) and prolactin, but no trends could be established. Likewise, three patients had marked elevations of luteinizing hormone and lesser elevations of follicle-stimulating hormone, but no pattern was discernible. The level of thyroid-stimulating hormone was stable and remained in the normal range throughout. GH was measured after intravenous glucose loading. A paradoxical rise reverted to normal at the late follow-up evaluation. It is suggested that the abnormal levels were related to abnormal hypothalamic function rather than to pituitary damage.

Cerebrospinal fluid pseudocysts: sonographic appearance and clinical management

Eight patients with 10 intraperitoneal cerebrospinal fluid pseudocysts occurring as a complication of ventriculoperitoneal (VP) shunt procedure were reviewed to determine the sonographic characteristics as well as the etiologic basis for the pseudocysts. An additional 10 patients with VP shunts, being routinely evaluated for genitourinary tract abnormality, were reviewed to determine the sonographic characteristics and the amount of fluid present in the abdomen with a normally functioning VP shunt in place. We found that a small amount or no peritoneal fluid is found in the patient with a normally functioning VP shunt. Larger, localized, simple or loculated fluid collections are abnormal and compatible with pseudocyst formation. Debris was identified in the majority of the fluid collections. We believe that ultrasonography is the method of choice in evaluation of complications of the distal end of the VP shunt. Our series suggests that infection is the principle cause for pseudocyst development despite the frequent absence of systemic signs of infection. Appropriate treatment involves removal of the peritoneal catheter and treatment of the infection. The catheter may later be replaced intraperitoneally.

Treatment of Infected Ventricular Shunts

25 shunt infections following 23 vascular and 2 peritoneal shunts are reviewed, thus enlarging a previous review. Intraventricular administration of antibiotics are essential to reach the CSF beyond the blood-SF barrier, the tubing and the valve. Methicillin in dosages of 25-50 mg/day, intraventricularly combined with systemic therapy, have been used most often in this series. The only death in this series occurred when the infection was cured. The remaining 24 have no evidence of residual infection following 6 months to 5 years. Only 14 have had shunt removal. The results indicate that shunt removal should not be the initial means of treating infected shunts.

Contributions of angiography to the pathophysiology of subdural hematomas

LITERATURE concerning the morbid anatomy, diagnosis, and treatment of posttraumatic subdural hematoma has adequately emphasized those aspects of the overall problem. It has generally been assumed that surgical evacuation of a hematoma is imperative and only recently have sporadic cases of spontaneous recovery been documented. While surgical drainage has been universally performed, surprisingly few observations on the intracranial events occurring after hematoma drainage have appeared. It seemed that a clearer understanding of the pathological physiology operating during the development of a subdural hematoma might be obtained by observing the anatomic events occurring intracranially during the postoperative period and comparing these events with the clinical recovery. Browder and Rabinerl have emphasized the role of cerebral swelling in the clinical course of patients with subacute and chronic snbdural hematomas. I t seemed that this factor could be evaluated, in addition to residual or recurrent surface accumulation postoperatively, by arteriography. A series of 22 patients have been studied by this means. Twenty-one had surgical evacuation of hematomas while 1 patient showed spontaneous resolution of the hematoma during repeated arteriographic observation. In each case a preoperative study and 1 to 4 postoperative arteriograms were performed.

Infected Ventriculo‐atrial Shunts: Some Principles of Treatment

The authors review 20 cases of shunt infection. Using intraventricular and systemic antibiotics, 12 cases have remained asymptomatic for over one year, and are thought to be cured of infection. Another 5 patients have remained asymptomatic for between 5 and 12 months. Ten patients have had shunt replacement in addition to antibiotic therapy, while the other 10 have been treated without surgical shunt replacement. The authors conclude, therefore, that vigorous, intensive antibiotic therapy is successful in a significant number of patients and that sacrifice or replacement of the shunt is not invariably necessary.

Nonsurgical cure of brain abscess in a neonate

A 7-day-old girl was found to have meningitis due to Staphylococcus aureus and a left parietal brain abscess. Six weeks treatment with intravenous methicillin resulted in resolution of her right hemiparesis and brain abscess. This is one of the youngest patients successfully treated by medical therapy alone. The case suggests that in carefully selected, closely monitored infants, medical therapy alone can be successful.

Sonography of Traumatic Cranial Hemorrhage

A large body of literature has accumulated during the past decade concerning the value of sonography in the diagnosis of intracranial hemorrhage in neonates. Most of this literature has dealt with the hemorrhages of germinal matrix origin occurring in the premature infant 1. 10. There has been very little written about the value of this diagnostic modality in the management of traumatic intracranial hemorrhage. For example, in a recently published monograph on pediatric head trauma there is only one illustration of a sonogram and no description of its use as a diagnostic tool11. This is partially related to the relative infrequency of traumatic hemorrhage in infancy. It seems appropriate, therefore, to review the role of sonography in craniocerebral trauma of infancy.

EFFECTS OF HEAD INJURY ON METABOLISM AND OTHER ORGAN SYSTEMS

Injury to the brain cannot be treated as an isolated event but must be considered in its proper physiological setting. Since management of most head injuries is non-surgical, it follows that appropriate treatment consists mainly of establishing and supporting the optimum milieu to promote recovery of the damaged brain. It is essential, therefore, that the secondary effects of the injury on other organ and metabolic systems be recognized. The following discussion summarizes the present knowledge regarding such secondary effects and includes recommendations for recognition and treatment.