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Biomedical subjects

L F Marshall

Publications and source records attributed to L F Marshall.

At least 19 recordsLinked to original sources
PubMed1992

Predictors of mortality in severely head-injured patients with civilian gunshot wounds: a report from the NIH Traumatic Coma Data Bank.

Predictors of outcome were examined in this prospective study of 151 patients severely injured by civilian gunshot wounds. Of the 151 patients, 133 (88%) died. Of the 123 patients with an initial Glasgow Coma Scale score of 3-5, 116 (94%) died, whereas of the 20 with an initial Glasgow Coma Scale score of 6-8, 14 (70%) died. There were no good outcomes, and only three moderate recoveries in patients who had initial scores of 8 or less. In those patients who survived long enough for intracranial pressure monitoring, intracranial hypertension predicted a very poor outcome. Computed tomographic scan characteristics such as midline shift, compression or obliteration of the mesencephalic cisterns, the presence of subarachnoid blood, intraventricular hemorrhage, and the presence of hyperdense or mixed-density lesions greater than 15 mL, either bilateral or unilateral, were all associated with a poor outcome. However, neither the caliber of gun nor the distance of the gun from the head significantly affected the risk of dying.

Adolescent↗
PubMed1992

Severe head injury in children: experience of the Traumatic Coma Data Bank.

The outcome at discharge, 6 months, and 1 year after they had sustained severe head injuries was investigated in children (0-15 yr old at injury) who were admitted to the neurosurgery service at one of four centers participating in the Traumatic Coma Data Bank. Of 103 eligible children, the quality of recovery was assessed by the Glasgow Outcome Scale (GOS) at 6 months after injury in 92 patients (86% of series) and at 1 year in 82 patients (73% of series). The lowest post-resuscitation Glasgow Coma Scale score and pupillary reactivity were predictive of the 6-month GOS as were their interaction. Analysis of the first computed tomographic scan disclosed that bilateral swelling with/without midline shift was related to a poor outcome as was the presence of mass lesions. Comparison of age-defined subgroups of patients revealed that outcome was poorest in the 0- to 4-year-old patients, as reflected by their mortality, which increased to 62% by 1 year. Distinctive features of the injuries in the 0- to 4-year-olds included evacuated subdural hematomas (20% of patients) and hypotension (32% of patients). The most favorable outcome was attained by 5- to 10-year-olds (2/3 had a good recovery by 1 yr), whereas the GOS distribution of adolescents was intermediate between the children and adults. In summary, the GOS data reflect heterogeneity in the quality of outcome after severe head injury depending on age, neurological indices, and computed tomographic scan diagnostic category.

Adolescent↗
PubMed1992

Methylprednisolone or naloxone treatment after acute spinal cord injury: 1-year follow-up data. Results of the second National Acute Spinal Cord Injury Study.

The 1-year follow-up data of a multicenter randomized controlled trial of methylprednisolone (30 mg/kg bolus and 5.4 mg/kg/hr for 23 hours) or naloxone (5.4 mg/kg bolus and 4.0 mg/kg/hr for 23 hours) treatment for acute spinal cord injury are reported and compared with placebo results. In patients treated with methylprednisolone within 8 hours of injury, increased recovery of neurological function was seen at 6 weeks and at 6 months and continued to be observed 1 year after injury. For motor function, this difference was statistically significant (p = 0.030), and was found in patients with total sensory and motor loss in the emergency room (p = 0.019) and in those with some preservation of motor and sensory function (p = 0.024). Naloxone-treated patients did not show significantly greater recovery. Patients treated after 8 hours of injury recovered less motor function if receiving methylprednisolone (p = 0.08) or naloxone (p = 0.10) as compared with those given placebo. Complication and mortality rates were similar in either group of treated patients as compared with the placebo group. The authors conclude that treatment with the study dose of methylprednisolone is indicated for acute spinal cord trauma, but only if it can be started within 8 hours of injury.

Acute Disease↗
PubMed1992

Diffuse brain swelling in severely head-injured children. A report from the NIH Traumatic Coma Data Bank.

In this study, data were prospectively collected from 753 patients (111 children and 642 adults) with severe head injury and examined for evidence of diffuse brain swelling and its association with outcome. Diffuse brain swelling occurred approximately twice as often in children (aged 16 years or younger) as in adults. A high mortality rate (53%) was found in these children, which was three times that of the children without diffuse brain swelling (16%). Adults with diffuse brain swelling had a mortality rate (46%) similar to that of children, but only slightly higher than that for adults without diffuse brain swelling (39%). When the diagnosis of diffuse brain swelling was expanded to include patients with diffuse brain swelling plus small parenchymal hemorrhages (less than 15 cu cm), these mortality rates were virtually unchanged.

Adolescent↗
PubMed1992

Extracranial complications of severe head injury.

In order to define the role of intracranial and extracranial complications in determining outcome from severe head injury, 734 patients from the Traumatic Coma Data Bank were analyzed. Nine classes of intracranial and 13 classes of extracranial complications occurring within the first 14 days after admission were analyzed, while controlling for age, admission Glasgow Coma Scale motor score, early hypoxia or hypotension, and severe extracranial trauma. Outcome for survivors was based on the last recorded Glasgow Outcome Scale score, obtained a median of 521 days after injury. Intracranial complications did not significantly alter outcome for the study group. Of the extracranial complications, pulmonary, cardiovascular, coagulation, and electrolyte disorders occurred most frequently at 2 to 4 days. Infections developed later, peaking at 5 to 11 days. Gastrointestinal, renal, and hepatic complications followed no specific time course. Electrolyte abnormalities were the most frequent occurrence (59% of patients) but did not alter outcome. Pulmonary infections (41%), shock (29%, systemic blood pressure < or = 90 mm Hg for 30 minutes or more), coagulopathy (19%), and septicemia (10%) were significant independent predictors of an unfavorable outcome. Backward-elimination, stepwise logistic regression modeling indicated that the estimated reduction of unfavorable outcome was 2.9% for the elimination of pneumonia, 3.1% for coagulation disturbances, 1.5% for septicemia, and 9.3% for shock. These data suggest that extracranial complications are highly influential in determining the outcome from severe head injury and that significant improvements in outcome in a sizeable proportion of patients could be accomplished by improving the ability to prevent or reverse pneumonia, hypotension, coagulopathy, and sepsis.

Adolescent↗
PubMed1992

The diagnosis of head injury requires a classification based on computed axial tomography.

The introduction of structural imaging of the brain by computed tomography (CT) scans and magnetic resonance imaging (MRI) has further refined classification of head injury for prognostic, diagnosis, and treatment purposes. We describe a new classification scheme to be used both as a research and a clinical tool in association with other predictors of neurologic status.

Adult↗
PubMed1991

Vegetative state after closed-head injury. A Traumatic Coma Data Bank Report.

To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury available for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious survivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury complicated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state.

Adolescent↗
PubMed1991

Intracranial hypertension in relation to memory functioning during the first year after severe head injury.

The relationship between intracranial hypertension and residual memory deficit after closed head injury was evaluated using the 6-month and 1-year neurobehavioral outcome data obtained by the Traumatic Coma Data Bank. Intracranial pressure was analyzed using the percentage of time that it exceeded 20 mm Hg and the maximum value recorded during the first 72 hours after injury. Memory measures included recall of word lists, prose recall, and visual memory for designs that were obtained 6 months (n = 149) and 1 year (n = 132) after injury. Intracranial hypertension occurred in more than half of the Traumatic Coma Data Bank cohort who met the criteria for the neurobehavioral follow-up study. Linear regression analysis disclosed an effect of elevated intracranial pressure on some, but not all, measures of memory at 6 months, whereas the results were negative for the 1-year follow-up examination. We conclude that the elevation of intracranial pressure exerts little if any effect on later memory functioning, and that any effect it does have diminishes over 1 year in survivors of severe head injury.

Adult↗
PubMed1991

Blunt injuries to the extracranial cerebral vessels associated with spine fractures.

Injury of the extracranial carotid or vertebral artery with associated spine fractures is a rare but documented entity. In this article, four cases are examined in which patients suffered axial fractures after motor vehicle accidents and subsequently were found to have pathology in one or more of the extracranial arteries. Misdiagnosis is a common complication because symptoms from this are often attributable to closed head injury. Early detection and treatment, however, are essential. As many as 40% of the cases reported have permanent neurologic deficit. Although cerebral angiography remains the diagnostic gold standard, other modalities (eg, transcranial doppler and magnetic resonance angiography) continue to be examined. The treatment of these lesions remains controversial. A variety of surgical procedures may be applicable depending on the time between the injury and the onset of symptoms, the location of the vascular injury, and the rapidity of diagnosis. Anticoagulation therapy appears to play a large role in the management of patients with injury of the extracranial carotid or vertebral artery.

Adult↗
PubMed1991

Management of head injury. Treatment of abnormal intracranial pressure.

Intracranial hypertension is recognized as a fundamental pathophysiologic process in brain injury. Although the exact pressure level defining intracranial hypertension remains to be firmly established, the majority of evidence available currently suggests that ICP should generally be treated when it exceeds 20 mm Hg. We suggest that lesions in the temporal lobe be treated at 15 mm Hg owing to the special relationship of this region to the brain stem. Along with the individual intracranial pressure reading, however, the course of the pressure over time and the status of the intracranial compliance as reflected in the ICP waveform must be considered when evaluating the intracranial dynamics. There is mounting evidence that patients with intracranial hypertension may comprise a heterogeneous group and that subgroups differ in their optimal treatment strategies. Although we cannot as yet identify such groups, factors such as age, CT diagnosis, responsiveness to hyperventilation, pressure-volume index, and ICP waveform are emerging as important differentiating factors. In particular, young patients with absent perimesencephalic cisterns and a tight brain on CT scan who manifest intracranial hypertension may comprise a group more suitable for treatment with hyperventilation and hypnotics than with osmotic agents. Although this is yet to be firmly established, currently it should be considered when such a patient responds poorly early in the course of conventional therapy for raised ICP. Treatment of intracranial hypertension remains rooted in the conventional therapeutic maneuvers. Maintenance of the basic homeostatic state of the patient is to be supplemented with head elevation, sedation, pharmacologic paralysis, hyperventilation, CSF drainage, and osmotic therapy as indicated. Outside of the special considerations discussed earlier, barbiturates should only be considered in patients with refractory intracranial hypertension without preexisting cardiovascular contraindications. Although several other agents have shown promise, currently the most exciting agent appears to be etomidate, which may prove quite useful. As ICP is better defined and understood, many significant and experimentally approachable questions are recognized. The basic mechanisms of raised ICP are slowly becoming elucidated. Clinical clues with which to subdivide patients with intracranial hypertension are being defined. New agents with efficacy in lowering raised ICP are appearing, and determination of their mechanisms of action may provide insight into the underlying disorder.

Brain Edema↗
PubMed1990

Large and small "holes" in the brain: reversible or irreversible changes in head injury.

We prospectively studied the frequency and course of large (greater than 25 cc) and small (less than 25 cc) areas of decreased density in 491 patients with severe closed head injury entered into the Traumatic Coma Data Bank (TCDB). The frequency of such areas and of subarachnoid haemorrhage on initial and subsequent CT scans were recorded. The frequency of large "holes" increased from 8 on the initial CT scan to 24 on scans done from day 4 to day 10. Half of these lesions either completely or almost completely resolved 14 days or more following injury. In patients with small "holes" the frequency increased from 24 to 77, but on scans performed 14 days or more following injury, 47% had completely disappeared. The presence of subarachnoid haemorrhage on the initial scan predicted the development of large areas of decreased density, but it did not predict the development of small areas of decreased density. The disappearance of a substantial number of these areas of decreased density ("holes") indicate that these areas do not necessarily represent areas of cerebral infarction. Patients with closed head injury are at risk for the development of what appear to be regional areas of cerebral ischaemia, but subarachnoid haemorrhage only predicts the development of large areas with these changes. Pharmacologic trials with calcium channel blocking agents or NMDA receptor antagonists in head injured patients appear warranted.

Brain↗
PubMed1990

Catecholamine and thyroid hormones in traumatic injury.

During hyperthyroidism, hypothyroidism, and severe stress there is often an inverse relationship between plasma norepinephrine (NE) and thyroid hormones. We evaluated this relationship in patients who were severely burned, patients who had injury to both brain and body, patients with head injury, and patients receiving high dose barbiturates for head injury. Head-injured patients had a low thyroxine (T4), low triiodothyronine (T3), and high reverse T3. Phenytoin for control of seizures lowered T3 and T4 and increased thyroid-stimulating hormone. Burned patients had a strong negative correlation between NE and T3 (r = -.88, p less than .001). Patients with injury to both brain and body had a weak negative correlation between NE and T3 (r = -.5, p = .06). Patients with head injury showed no correlation between NE and T3. Severely injured patients had a close inverse relationship between elevated NE levels and depressed T3 levels. This relationship appears to depend on an intact CNS, as the relationship was disrupted by head injury and barbiturates.

Adolescent↗
PubMed1990

Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank.

In this prospective multicenter study, the authors have examined data derived from the initial computerized tomography (CT) scans of 753 patients with severe head injury. When the CT findings were related to abnormal intracranial pressure and to death, the most important characteristics of the scans were: midline shift: compression or obliteration of the mesencephalic cisterns: and the presence of subarachnoid blood. Diffuse hemispheric swelling was also found to be associated with an early episode of either hypoxia or hypotension.

Brain Injuries↗
PubMed1989

Determinants of head injury mortality: importance of the low risk patient.

Data were obtained prospectively for 7,912 head-injured patients admitted from 1980 to 1981 to 41 hospitals in 3 U.S. metropolitan areas. Highly significant independent predictors of mortality were motor score, number of reactive eyes, systolic blood pressure, abdominal injury, chest injury, age, and hospital unit (hospital or group of hospitals). The difference between the number of deaths observed and the number expected, by hospital unit, ranged from 43% below expectation to 52% above expectation. The 2 hospital units with the lowest mortality had only 1 death, where 9.4 would be expected, in patients whose risk of death was estimated to be less than 10%. In the single hospital with clearly excess mortality, however, the standardized mortality ratios were 208, 135, and 144% for the risk groups whose probabilities of death were 0 to 50, 50 to 80, and 80 to 100%, respectively. The lack of deaths in those hospitals with the best mortality experience and the excess mortality in the hospital with the worst mortality experience appear to be explained largely by differences in patients who, by clinical criteria, seem to be at low risk for death, and not by severely injured patients.

Adolescent↗
PubMed1989

Care of the multiply injured patient with cervical spine injury.

Cervical spine injuries can be disastrous. The treatment begins at the accident scene by obtaining an appropriate history, physical examination, and evaluation of the mechanics of the accident. Emergency medical stabilization takes precedence, but the cervical spine should be stabilized until an injury in this area is ruled out. If the patient has suffered a head injury or is violent, cervical spine precautions should be maintained until spinal column injuries have been ruled out roentgenographically. Because of the complexities of the evaluation and treatment of cervical spine injury in the multiply injured patient, an algorithm to assist in the management and evaluation of the patient has been developed, and a multidisciplinary, specialized evaluation and treatment team is employed. Through this approach, mortality in the multiply injured patient with a cervical spine injury has been reduced to 22%. Of 58 patients with cervical spine injuries evaluated by this aggressive approach, 14 patients had associated spine fractures, and 9 patients had positive peritoneal lavage requiring surgical exploration. Injuries involving other organ systems were also diagnosed and treated. Formal, rigid evaluation plans and aggressive multidisciplinary treatment are useful in saving the lives and salvaging neurologic function of these patients.

Algorithms↗
PubMed1988

Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury.

A series of 8814 head-injured patients admitted to 41 hospitals in three separate metropolitan areas were prospectively studied. Of these, 1906 patients (21.6%) were 14 years of age or less. This "pediatric population" was compared to the remaining "adult population" for mechanism of injury, admission Glasgow Coma Scale score, motor score, blood pressure, pupillary reactivity, the presence of associated injuries, and the presence of subdural or epidural hematoma. The relationship of each of these factors was then correlated with post-traumatic mortality. Except for patients found to have subdural hematoma and those who were profoundly hypotensive, the pediatric patients exhibited a significantly lower mortality rate compared to the adults, thus confirming this generally held view. This study indicates that age itself, even within the pediatric age range, is a major independent factor affecting the mortality rate in head-injured patients.

Adolescent↗