Steven K. Gudeman

Papilledema after acute head injury.

Low grade papilledema after acute, severe head injury was identified in 15 (3.5%) of 426 patients. Papilledema was recognized immediately after head injury in 1 patient, during the 1st week in 10 patients, and in the 2nd week or after in 4 patients. Initial computed tomographic scans showed evidence of brain injury in 11 of these patients. The intracranial pressure (ICP) was monitored continuously for 3 or more days in 9 patients; it was mildly elevated (20 to 40 mm Hg) in 7 patients and moderately elevated (40 to 60 mm Hg) in 2 patients. Intracranial hypertension was controllable in each patient. A sudden, severe, but transient increase in ICP best explained the immediate development of papilledema and survival of 1 patient. Sustained but mild to moderately elevated ICP accounted for papilledema appearing in the 1st week. Papilledema in the 2nd week or after occurred from impaired cerebrospinal fluid absorption and consequent communicating hydrocephalus or delayed focal or diffuse cerebral swelling. A lesser degree of head injury in patients with posttraumatic papilledema was suggested by a higher Glasgow coma score, milder and controllable elevations in ICP, and the absence of any fatality in this group. The favorable outcome was significant compared to the mortality of the more severely injured patients (chi square-4.327; P less than 0.04). Papilledema did not occur in 6 patients with sustained, severely elevated ICP (greater than 60 mm Hg) for 3 or more days. Each of these patients died. The severity of the trauma apparently accounts for the failure of papilledema to develop, possibly by arresting axoplasmic production and transport in retinal nerve fibers.

Gastric secretory and mucosal injury response to severe head trauma.

The problem of gastric secretory and mucosal injury response was evaluated in 19 patients who had suffered a severe head injury. Fifteen of 19 patients had some evidence of gastrointestinal hemorrhage. In 7 cases, this was marked. The mean volume of gastric secretions ranged from 36.4 ml/hour on Day 1 to 47.6 ml/hour on Day 6. The mean value of titratable acidity ranged from 3.4 meq/hour on Day 1 to 3.9 meq/hour on Day 6. Possible risk factors were analyzed as a means of predicting specific subgroups of severely injured patients who would be more prone to have gastrointestinal complications. During the first 6 days after injury, there was no significant association (correlation coefficient not significant at the 0.05 level of significance) of the presence of an intracranial mass lesion, elevated intracranial pressure, brain stem dysfunction or prior episodes of hypotension or hypoxia, sepsis, shock, or the requirement for pressor agents with elevated gastric acid output, mucosal erosion, or hemorrhage. Because no specific risk factor or factors could be identified, all severely brain-injured patients should be on some form of therapy for the prevention of gastrointestinal complications.

CT Scan, ICP and Early Neurological Evaluation in the Prognosis of Severe Head Injury

The prognostic value of careful neurological evaluation using standard terminology performed serially over 72 hours in patients with head injuries of designated severity has been shown by Jennett and his colleagues. The growing use of muscle relaxants with artificial ventilation and the increasing interest in the use of induced barbiturate coma reduces the opportunity for serial neurological evaluations over an extended period. Furthermore, there is a need to identify at the earliest possible stage those patients in whom a particularly poor outcome is to be expected, because it is in this group that newer and perhaps riskier therapies are justified. Inclusion of patients in whom a better outcome is to be expected may yield a falsely optimistic view of a test therapy. One solution is to wait for a certain period of time to ascertain that the head injury is serious. This has the disadvantage that it may delay application of therapy to a point where no treatment can be effective because neurological deterioration has become irreversible.

Unilateral proptosis secondary to a retroorbital tumor: fibrous histiocytoma or xanthogranulomatous lesion.

Abstract A patient was first examined because of unilateral decreased vision, proptosis, and generalized headaches secondary to a retro-orbital tumor. An unusual orbital tumor with intracranial in-volvement was found. The pathological diagnosis was fibrous histiocytoma or xanthogranulomatous lesion.