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T T Lee

Publications and source records attributed to T T Lee.

At least 19 recordsLinked to original sources

His68 and His141 are critical contributors to the intersubunit catalytic site of adenylosuccinate lyase of Bacillus subtilis.

Mutant adenylosuccinate lyases of Bacillus subtilis were prepared by site-directed mutagenesis with replacements for His141, previously identified by affinity labeling as being in the active site [Lee, T. T., Worby, C., Dixon, J. E., and Colman, R. F. (1997) J. Biol. Chem. 272, 458-465]. Four substitutions (A, L, E, Q) yield mutant enzyme with no detectable catalytic activity, while the H141R mutant is about 10(-)5 as active as the wild-type enzyme. Kinetic studies show, for the H141R enzyme, a Km that is only 3 times that of the wild-type enzyme. Minimal activity was also observed for mutant enzymes with replacements for His68 [Lee, T. T., Worby, C., Bao, Z. -Q., Dixon, J. E., and Colman, R. F. (1998) Biochemistry 37, 8481-8489]. Measurement of the reversible binding of radioactive adenylosuccinate by inactive mutant enzymes with substitutions at either position 68 or 141 shows that their affinities for substrate are decreased by only 10-40-fold. These results suggest that His141, like His68, plays an important role in catalysis, but not in substrate binding. Evidence is consistent with the hypothesis that His141 and His68 function, respectively, as the catalytic base and acid. Circular dichroism spectroscopy and gel filtration chromatography conducted on wild-type and all His141 and His68 mutants reveal that none of the mutant enzymes exhibits major structural changes and that all the enzymes are tetramers. Mixing inactive His141 with inactive His68 mutant enzymes leads to striking increases in catalytic activity. This complementation of mutant enzymes indicates that His141 and His68 come from different subunits to form the active site. A tetrameric structure of adenylosuccinate lyase was constructed by homology modeling based on the known structures in the fumarase superfamily, including argininosuccinate lyase, delta-crystallin, fumarase, and aspartase. The model suggests that each active site is constituted by residues from three subunits, and that His141 and His68 come from two different subunits.

Adenosine Monophosphate

Treatment of stable burst fracture of the atlas (Jefferson fracture) with rigid cervical collar.

STUDY DESIGN: A retrospective review of a clinical series. OBJECTIVE: To evaluate the use of a rigid cervical collar alone as the treatment for stable Jefferson fracture, and to devise an algorithm for treatment of Jefferson fracture with or without an associated cervical injury. SUMMARY OF BACKGROUND DATA: The traditional treatment for Jefferson fracture, if there is no indication for surgery, is immobilization by halo vest. Because halo vest placement is associated with intracranial infection and a significant degree of patient discomfort, slightly less rigid forms of external immobilization may be useful for the treatment of stable Jefferson fractures. No standard protocol calling for the use of one form of stabilization device has been reported. MATERIALS: The medical records and radiographs of 16 consecutive patients with Jefferson fracture during a 2-year period were reviewed. Each patient underwent a complete cervical radiograph series and a computed tomographic scan. The mean C1 lateral mass displacement was 1.8 mm. Cervical spine radiographs, including lateral flexion-extension views were obtained 10 to 12 weeks after injury before the removal of an external immobilization device. RESULTS: Of these 16 patients, 1 sustained a complete injury, and 7 sustained an incomplete injury. Eight patients were neurologically intact. Twelve patients sustained a stable Jefferson fracture and were treated with a rigid cervical collar (Miami-J collar [Jerome Medical, Moorestown, NJ]) alone from 10 to 12 weeks. The patient sustaining the complete neurologic injury died of multisystem trauma. All 15 live patients showed no instability on their follow-up plain radiographs before the removal of an external stabilization device. Six patients underwent further plain radiographs approximately 1 year after the fracture and similarly demonstrated no instability. CONCLUSIONS: Isolated stable burst fracture of the atlas can be treated effectively with a rigid cervical collar alone for 10 to 12 weeks with good neurologic recovery and segmental stability. Unstable Jefferson fractures with concurrent unstable fracture of other cervical vertebrae, especially C2, requires surgical stabilization.

Adolescent

Implication of His68 in the substrate site of Bacillus subtilis adenylosuccinate lyase by mutagenesis and affinity labeling with 2-[(4-bromo-2,3-dioxobutyl)thio]adenosine 5'-monophosphate.

Adenylosuccinate lyase of Bacillus subtilis is inactivated by 2-[(4-bromo-2,3-dioxobutyl)thio]adenosine 5'-monophosphate (2-BDB-TAMP) at pH 7.0. As the reagent concentration is increased, a maximum rate constant is approached, indicative of reversible enzyme-reagent complex formation (KR = 68 +/- 9 microM) prior to irreversible modification (kmax = 0.081 +/- 0.004 min-1). Complete inactivation occurs concomitant with about 1 mol of 2-BDB-[14C]TAMP incorporated/mol of enzyme subunit. Adenylosuccinate, or a combination of AMP and fumarate, decreases the inactivation rate and reduces incorporation of [14C] reagent, whereas either AMP or fumarate alone is much less effective. These observations suggest that 2-BDB-TAMP attacks the adenylosuccinate binding site. Proteolytic digestion of inactivated enzyme, followed by purification of the digest by HPLC, yields the radioactive peptide Ile62-Ala72, in which Arg67 and His68 are the most likely targets. Thus 2-BDB-TAMP reacts with adenylosuccinate lyase at a site distinct from the His141 attacked by 6-BDB-TAMP (Lee, Worby, Dixon, and Colman (1997) J. Biol. Chem. 272, 458-465). Site-directed mutagenesis was used to construct mutant enzymes with replacements for both Arg67 and His68, and either Arg67 or His68. The R67M mutant enzyme has almost the same specific activity as the wild-type enzyme under standard assay conditions, whereas the single mutant H68Q and double mutant R67M-H68Q enzymes exhibit specific activities that are decreased more than 100-fold. These results indicate that while Arg67 and His68 may both be in the region of the substrate site, only His68 is important for the catalytic activity of B. subtilis adenylosuccinate lyase. A role is proposed for His68 as a general acid-base catalyst.

Adenylosuccinate Lyase

Traumatic spinal cord injury induces nuclear factor-kappaB activation.

Inflammatory responses are a major component of secondary injury and play a central role in mediating the pathogenesis of acute and chronic spinal cord injury (SCI). The nuclear factor-kappaB (NF-kappaB) family of transcription factors is required for the transcriptional activation of a variety of genes regulating inflammatory, proliferative, and cell death responses of cells. In this study we examined the temporal and cellular expression of activated NF-kappaB after traumatic SCI. We used a contusion model (N.Y.U. Impactor) to initiate the early biochemical and molecular changes that occur after traumatic injury to reproduce the pathological events associated with acute inflammation after SCI. The activation and cellular distribution of activated NF-kappaB was evaluated by using a monoclonal antibody that selectively recognizes activated p65 in a NF-kappaB dimer. Immunohistochemical and Western blot analyses demonstrated that NF-kappaB activation occurred as early as 0.5 hr postinjury and persisted for at least 72 hr. Using electrophoretic mobility shift assays (EMSA), we demonstrate that NF-kappaB is activated after SCI. In our immunohistochemical, Western, and EMSA experiments there are detectable levels of activated NF-kappaB in our control animals. Using double-staining protocols, we detected activated NF-kappaB in macrophages/microglia, endothelial cells, and neurons within the injured spinal cord. Colocalization of activated NF-kappaB with the NF-kappaB-dependent gene product, inducible nitric oxide synthase (iNOS), suggests functional implications for this transcription factor in the pathogenesis of acute spinal cord injury. Although there is considerable evidence for the involvement of an inflammatory reaction after traumatic SCI, this is the first evidence for the activation of NF-kappaB after trauma. Strategies directed at blocking the initiation of this cascade may prove beneficial as a therapeutic approach for the treatment of acute SCI.

Animals

Diffuse axonal injury (DAI) is not associated with elevated intracranial pressure (ICP).

OBJECTIVE: Traditionally, intracranial pressure (ICP) monitoring has been utilized in all patients with severe head injury (Glasgow coma score of 3-8). Ventriculostomy placement, however, does carry a 4 to 10 percent complication rate consisting mostly of hematoma and infection. The authors propose that a subgroup of patients presenting with severe head trauma and diffuse axonal injury without associated mass lesion, do not need ICP monitoring. Additionally, the monitoring data from ICP, MAP, and CPP for a comparison severe head injury group, and subgroups of DAI would be presented. MATERIALS AND METHODS: Thirty-six patients sustaining blunt head trauma and fitting our strict clinical and radiographic diagnosis of DAI were enrolled in our study. Inclusion criteria were severe head injury patients who did not regain consciousness after the initial impact, and whose CT scan demonstrated characteristic punctate hemorrhages of < 10 mm diameter at the greywhite junction, basal ganglia, corpus callosum, upper brainstem, or a combination of the above. Patients with significant mass lesions and documented anoxia were excluded. Their intracranial pressure (ICP) and cerebral perfusion pressure (CPP) were compared to a control group of 36 consecutive patients with severe non-penetrating non-operative head injury, using the Analysis for Variance method. RESULTS: Eighteen (50.0%), six (16.7%), and twelve (33.3%) patients had types I, II, and III DAI, respectively. The admission Glasgow Coma Score (GCS) was higher for types I and II than for type III DAI. ICP was monitored from 23 to 165 hours, with a mean ICP for 36 patients of 11.70 mmHg (SEM = 0.75) and a range from 4.3 to 17.3 mmHg. Of all ICP recordings, of which 89.7%, (2421/2698) were < or = 20 mmHg. Average mean arterial pressure (MAP) was 96.08 mmHg (SEM = 1.69), and 94.6% (2038/2154) of all MAP readings were greater than 80 mmHg. Average cerebral perfusion pressure (CPP) was 85.16 mmHg (SEM = 1.68), and 90.1% (1941/2154) of all CPP readings were greater than 70 mmHg. This is compared to the control group mean ICP, MAP, and CPP of 16.84 mmHg (p = 0.000021), 92.80 mmHg (p = 0.18), and 76.49 mmHg (p = 0.0012). No treatment for sustained elevated ICP > 20 mmHg was needed for DAI patients except in two; one with extensive intraventricular and subarachnoid hemorrhage who developed communicating hydrocephalus, and another with ventriculitis requiring intrathecal and intravenous antibiotic treatments. Two complications, one from a catheter tract hematoma, and another with Staph epidermidis ventriculitis, were encountered. All patients, except type III DAI, generally demonstrated marked clinical improvement with time. The outcome, as measured by Glasgow Coma Score (GCS) and Glasgow Outcome Score (GOS) was similarly better with types I and II than type III DAI. CONCLUSION: The authors conclude that ICP elevation in DAI patients without associated mass lesions is not as prevalent as other severe head injured patients, therefore ICP monitoring may not be as critical. The presence of an ICP monitoring device may contribute to increased morbidity. Of key importance, however, is an accurate clinical history and interpretation of the CT scan.

Adolescent

Surgical treatment of spinal ependymoma and post-operative radiotherapy.

INTRODUCTION: With the advances in microsurgical and monitoring techniques, spinal ependymomas are gross totally resected more frequently. The use of adjuvant radiotherapy has become questionable with gross total resection and its role for residual neoplasm need to be redefined. A retrospective analysis of a series of patients was carried out to investigate our clinical outcome and selected use of post-operative radiotherapy. CLINICAL MATERIALS AND METHODS: Between July 1990 and May 1995, nineteen patients [M : F = 12 : 7; age range: 21 to 71 years] with a spinal ependymoma were treated at University of Miami by the senior author. (BAG) Pre-operative MRI diagnosed the intraspinal tumor, and pathology reports demonstrated that each patient had a histologically confirmed ependymoma. At the time of diagnosis, the most common symptoms presented were pain (in 16 patients = 84.2%). The pattern of progression of clinical symptoms was directly related to the location of the tumor. Each patient had an MRI immediately after surgery, approximately 6 months post-operatively, and then annually. RESULTS: All 19 patients underwent intradural microsurgical exploration with an attempted gross total resection (achieved in 16 patients = 79%) of the ependymoma through a posterior approach. Direct neural tissue stimulation halted further resection in 2 patients with questionable tumor margins. Radiation therapy was employed as a surgical adjunct in 3 patients (15.8%) because of possible residual tumor. All patients were followed up postoperatively for an average of 50.6 months (range 6 months to 6 years). All patients are surviving to date. Surgical resection of these tumors led to significant alleviation of pre-operative symptom. There has been no radiographic evidence of tumor recurrence or growth in any patient to date. CONCLUSION: Surgical resection of spinal ependymoma leads to significant improvement of pre-operative symptoms. Surgical removal alone, with an attempt to grossly resect the tumor, should be the treatment of choice, with careful clinical and radiographic follow-up. Radiation therapy should only be considered as a surgical adjunct where gross total resection is not achieved.

Adult

Spinal metastases of malignant intracranial meningioma.

BACKGROUND: Spinal metastasis of intracranial meningiomas has rarely been reported. Three out of ten previously reported cases of malignant meningioma metastasizing to the spine had undergone surgical debulking with no neurological improvement. The authors retrospectively reviewed the treatment course of three patients with malignant meningioma metastasizing to the spine who underwent early magnetic resonance imaging (MRI) and radiotherapy without surgical debulking. CASE DESCRIPTION: Three patients with intracranial malignant meningiomas underwent multiple resections of intracranial lesions, and developed spinal intradural metastases an average of 64 months (range, 27-102 months) from their initial presentation. All three patients had at least two operations for recurrent intracranial tumors. All had localized back pain with motor weakness, and MRI scans demonstrated spinal involvement. No surgical exploration was performed for the spinal lesions; rather, all patients received steroids and radiotherapy for the spinal lesions. All three patients improved neurologically after the steroid and radiation treatments, and went on to survive from 3 to 18 months. CONCLUSION: Early MRI should be performed in patients with spinal symptoms and signs after the treatment of intracranial meningiomas. Radiotherapy is an effective palliative treatment for spinal metastases.

Adult

Exophytic malignant brainstem mixed glioma in an adult: a case report.

Anaplastic mixed gliomas are rare tumors that occur mostly in the cerebral hemispheres. They have a distinctive histological appearance characterized by the presence of two or more glial cellular constituents. The incidence of malignant mixed glioma of the brainstem and posterior fossa is extremely low. The authors report an unusual case of an exophytic malignant mixed glioma. Following subtotal resection, the patient received conventional radiotherapy, but continued to deteriorate, and died five months after surgery. The extensive literature review focuses on histopathology, clinical features, natural history, and possible treatment modalities of this unusual neoplasm.

Brain Neoplasms

Early combined management of frontal sinus and orbital and facial fractures.

BACKGROUND: Historically, frontal sinus fractures and associated maxillofacial fractures were addressed at different times. We retrospectively reviewed our experience with a series of 79 consecutive patients with bitable frontal sinus fractures, most with associated facial fractures, who underwent early combined cranial and maxillofacial procedures. METHODS: The operations were performed emergently for patients with open or depressed skull fractures and hematomas with mass effect, and electively within 2 weeks for those with closed fractures. The cranial procedures were performed first. The nasofrontal ducts were packed with "cigars" of bacitracin powder wrapped in Surgicel. All patients received antibiotics for 2 weeks. RESULTS: Postoperatively, good subjective cosmetic results were obtained except in one patient. Eight patients with lumbar drains had expected temporary cerebrospinal fluid (CSF) leaks of less than 72 hours duration. Six postoperative intracranial infections (four cases of meningitis, one epidural empyema, and one intracerebral abscess) were detected; five of these occurred in patients with open depressed fractures. Patients with preoperative CSF leaks (p = 0.0039, Fisher's exact test) and open fractures (p = 0.065, Fisher's exact test) were more likely to develop intracranial infections. CONCLUSION: The combined neurosurgical and maxillofacial repairs achieved good cosmetic outcomes, with relatively low morbidity. By combining the two-stage procedure into one stage, standard surgical and anesthetic risks could potentially be reduced. Preoperative CSF leaks and open fractures were associated with a higher incidence of postoperative central nervous system infection. Early operations did not appear to be associated with a higher complication rate.

Adolescent

Diagnostic and surgical management of spinal dural arteriovenous fistulas.

OBJECTIVE: A retrospective review was conducted to compare magnetic resonance (MR) and conventional spinal angiographic images and to investigate the outcome of our treatment protocol for patients with spinal dural arteriovenous fistulas (DAVFs). MATERIALS AND METHODS: Nine patients with a diagnosis of DAVF based on clinical myelopathy and preoperative MR imaging (MRI) and MR angiography (MRA) findings were treated at our institution by the senior author (BAG). All nine patients initially presented with progressive myelopathy. Preoperative MRI revealed T2-weighted signal abnormalities in all patients, and MRA was diagnostic in all patients. Each patient underwent a laminectomy and ligation of the arterialized draining vein. Selective spinal angiograms were used to confirm the level of fistula immediately before the surgical procedure was performed and to document complete obliteration after clip ligation of the medullary draining vein. Follow-up MRI and MRA were performed approximately 2 months postoperatively. RESULTS: MRI T2-weighted signal hyperintensity improved after surgery in all nine patients. Postoperatively, progression of motor weakness and gait difficulty was halted and some improvement was observed in all patients. No patient was neurologically normal, however. To date, there has been no clinical or MRA evidence of recurrence in any patient. CONCLUSION: Preoperative MRA and intraoperative spinal x-ray angiography present as an effective combination for diagnosing and intraoperatively confirming DAVF. Both T1-weighted enhancement and T2-weighted signal hyperintensity on MR images improved after the obliteration of the DAVFs and correlated with clinical improvement in all nine patients. MRA provides adequate visualization and localization of spinal DAVFs and may serve as a useful noninvasive tool for diagnosing and following patients with spinal DAVFs in the future.

Adult

Safety and stability of open-door cervical expansive laminoplasty.

Cervical expansive laminoplasty has been utilized for over 20 years. This retrospective analysis investigated the safety and incidence of postoperative instability of patients undergoing a modified expansive laminoplasty. One hundred five patients underwent a modified cervical expansive laminoplasty and had at least a 6-month follow-up. These 105 patients were followed for a mean of 18.6 months (range 6-89 months). All patients remained in a rigid cervical collar for 8-12 weeks after the laminoplasty. Postoperative cervical plain radiographs were obtained on postoperative day 1, an average of 9.6 weeks postoperatively (range 8-12 weeks) and an average of 10.1 months (range 6-12 months) postoperatively. Thirty-five patients underwent further radiographs >18 months postoperatively. Laminoplasty was performed in 82 patients with progressive cervical spondylotic myelopathy, 4 patients with ossification of the posterior longitudinal ligament, 7 patients for posterior approach to a cervical neoplasm, and 12 patients for early posttraumatic decompression. The canal/vertebral body ratio showed a significant increase from 0.78 to 1.02 (paired t test, p < 0.001). Postoperatively, no incidence of graft dislodgement or segmental instability was diagnosed in any patient. Modified open-door expansive laminoplasty is an effective way of expanding the spinal canal. Its associated low incidence of postoperative instability and kyphotic deformity should make this procedure a desirable substitute for cervical laminectomy under many circumstances.

Cervical Vertebrae

Empirically defined health states for depression from the SF-12.

OBJECTIVE: To define objectively and describe a set of clinically relevant health states that encompass the typical effects of depression on quality of life in an actual patient population. Our model was designed to facilitate the elicitation of patients' and the public's values (utilities) for outcomes of depression. DATA SOURCES: From the depression panel of the Medical Outcomes Study. Data include scores on the 12-Item Short Form Health Survey (SF-12) as well as independently obtained diagnoses of depression for 716 patients. Follow-up information, one year after baseline, was available for 166 of these patients. METHODOLOGY: We use k-means cluster analysis to group the patients according to appropriate dimensions of health derived from the SF-12 scores. Chi-squared and exact permutation tests are used to validate the health states thus obtained, by checking for baseline and longitudinal correlation of cluster membership and clinical diagnosis. PRINCIPAL FINDINGS: We find, on the basis of a combination of statistical and clinical criteria, that six states are optimal for summarizing the range of health experienced by depressed patients. Each state is described in terms of a subject who is typical in a sense that is articulated with our cluster-analytic approach. In all of our models, the relationship between health state membership and clinical diagnosis is highly statistically significant. The models are also sensitive to changes in patients' clinical status over time. CONCLUSIONS: Cluster analysis is demonstrably a powerful methodology for forming clinically valid health states from health status data. The states produced are suitable for the experimental elicitation of preference and analyses of costs and utilities.

Chi-Square Distribution

Cost-effectiveness of screening for carotid stenosis in asymptomatic persons.

BACKGROUND: The Asymptomatic Carotid Atherosclerosis Study (ACAS) showed that carotid endarterectomy was beneficial for symptom-free patients with carotid stenosis of 60% or more. This finding raises the question of whether widespread screening to identify cases of asymptomatic carotid stenosis should be implemented. OBJECTIVE: To determine whether a screening program to identify cases of asymptomatic carotid stenosis would be a cost-effective strategy for stroke prevention. DESIGN: Cost-effectiveness analysis using published data from clinical trials. SETTING: General population of asymptomatic 65-year-old men. INTERVENTION: Patients who were screened for carotid disease with duplex Doppler ultrasonography were compared with patients who were not screened. If ultrasonography found significant carotid stenosis (> or = 60%), disease was confirmed by angiography before carotid endarterectomy was done. MEASUREMENTS: Quality-adjusted life-years, costs, and marginal cost-effectiveness ratios. RESULTS: When the conditions and results of ACAS were modeled and it was assumed that the survival advantage produced by endarterectomy would last for 30 years, the lifetime marginal cost-effectiveness of screening relative to no screening was $120,000 per quality-adjusted life-year. Sensitivity analysis showed that marginal cost-effectiveness decreased to $50,000 or less per quality-adjusted life-year only under implausible conditions (for example, if a free screening instrument with perfect test characteristics was used or an asymptomatic population with a 40% prevalence of carotid stenosis was found). CONCLUSIONS: Surgery offers a real but modest absolute reduction in the rate of stroke at a substantial cost. A program to identify candidates for endarterectomy by screening asymptomatic populations for carotid stenosis costs more per quality-adjusted life-year than is usually considered acceptable.

Aged

Identification of His141 in the active site of Bacillus subtilis adenylosuccinate lyase by affinity labeling with 6-(4-bromo-2,3-dioxobutyl)thioadenosine 5'-monophosphate.

Adenylosuccinate lyase of Bacillus subtilis is inactivated by 25-400 microM 6-(4-bromo-2,3-dioxobutyl)thioadenosine 5'-monophosphate (6-BDB-TAMP) at pH 7.0 and 25 degrees C. The initial inactivation rate constant exhibits nonlinear dependence on the concentration of 6-BDB-TAMP, implying there is reversible formation of enzyme-reagent complex (K(I) = 30 +/- 4 microM) prior to irreversible modification (kmax = 0.139 +/- 0.005 min(-1)). The tetrameric enzyme incorporates about 1 mol of 6-BDB-[32P]TAMP per mol of enzyme subunit concomitant with complete inactivation. Protection against inactivation and incorporation of [32P]reagent is provided by adenylosuccinate or a combination of AMP and fumarate, whereas either AMP or fumarate alone is much less effective. These observations suggest that 6-BDB-TAMP targets the adenylosuccinate-binding site. Hydrolyzed 6-BDB-TAMP is a competitive inhibitor with respect to adenylosuccinate in the catalytic reaction and also decreases the rate of inactivation by 6-BDB-TAMP. These results account for the decrease in the inactivation rate as the reaction of 6-BDB-TAMP with the enzyme proceeds. Purification by chromatography on dihydroxyboryl-agarose and high performance liquid chromatography of the tryptic digest of inactivated enzyme yields a single radioactive peptide, Thr140-Phe150, as determined by gas-phase sequencing. Modified His141 is the reaction product of 6-BDB-TAMP and adenylosuccinate lyase. We conclude that 6-BDB-TAMP functions as a reactive adenylosuccinate analog in modifying His141 in the substrate-binding site of adenylosuccinate lyase, where it may serve as a general base accepting a proton from the succinyl group during catalysis.

Adenosine Monophosphate

Third ventricular glioblastoma multiforme: case report.

Intraventricular neoplasms of the third ventricle represent a small minority of intracranial tumors. Furthermore, few cases of solitary, third ventricular glioblastoma multiforme were reported in the literature. The authors report a case of a fifty-nine year old man who presented with progressive gait disturbance, disorientation, diffuse headache, and vomiting. Computed tomography and magnetic resonance imaging (MRI) confirmed a solitary third ventricular ring-enhancing lesion and obstructive hydrocephalus. The final pathology of the lesion upon permanent section was glioblastoma multiforme (GBM). The clinical course, radiologic findings, the possible origin of this lesion, as well as possible treatment regimen are discussed.

Brain Neoplasms

Follow-up computerized tomography (CT) scans in moderate and severe head injuries: correlation with Glasgow Coma Scores (GCS), and complication rate.

BACKGROUND: The wide availability of computerized tomography (CT) scan has popularized its use in initial and follow-up evaluations of head trauma patients. Follow-up CT scans of clinically stable patients, however, may not provide additional information, but could potentially subject the patients to secondary injuries. The authors investigated the correlation between CT scans and Glasgow coma score (GCS), and complication rate during follow-up CT scans in an attempt to dissuade clinicians from obtaining unnecessary follow-up CT scans. METHODS: The medical records of 180 patients with blunt head trauma were retrospectively reviewed. Only patients (117) with moderate and severe head injuries were included in the study. A total of 319 follow-up brain CT's for 94 patients were obtained. RESULTS: The change in CT scans was compared to the GCS the day of the scan. These two variables were found to be positively correlated by Chi-square analysis (chi 2 = 81.2; alpha < 0.001). CPP trend was found also be correlated with CT scan evolution by the Chi-square analysis (alpha < 0.001). When patients had unchanged or improved GCS, 73.1% had improved or the same CT appearance. When patients had a worse GCS, the CT was worse in 77.9%. A 16.9% (54/319) complication rate was documented during the follow-up scans (hemodynamic instability, increased intracranial pressure, desaturation, and agitation). This rate was higher in severe head trauma (GCS 3-8) patients than in moderate head injury (GCS 9-12) patients. Hemodynamic instability was the most common complication, which comprises 42.6% (23/54) of all complications. CONCLUSION: Because of the correlation between the CT scan appearance and the clinical status, as well as the detrimental effect of mobilizing critically ill patients, the authors urge the use of follow-up CT scans only in patients with clinical deterioration unexplained by ICP changes alone.

Blood Pressure

Orbital-frontal delayed hemorrhagic contusions: clinical course and neurosurgical treatment protocol.

BACKGROUND: Delayed posttraumatic hemorrhage into the underlying contusion could cause significant elevation of intracranial pressure (ICP) and dramatic clinical and radiographic deterioration. The authors identified a subgroup of young patients with initial mild/moderate head injury, who presented with orbito-frontal and temporal tip minimal punctate contusions, which within 24 hours, expanded into dramatically larger noncoalesced hemorrhagic contusions. METHODS: Four consecutive patients within a 13-month period admitted to our institution with the above radiographic picture are presented and their clinical and treatment courses compared. RESULTS: After observing the relentless downhill course of two earlier patients treated for the control of ICP, our treatment protocol changed to early prophylactic intubation and moderate hyperventilation, insertion of an intraventricular catheter for ICP monitoring, hyperosmolar therapy with mannitol, sedation, chemical paralytics, and eventually pentobarbital for control of increased ICP. These interventions were mostly taken before the radiographic evidence of contusion blossoming and dramatic clinical deterioration. These two subsequent patients had a prolonged course of intubation and ICP problems requiring tracheostomy placement. The clinical outcome was excellent, however, with both patients decanulated from the tracheostomy within 6 weeks, and both returned to relatively normal premorbid functions. CONCLUSION: Although the series consists only of four consecutive patients with similar radiographic appearances, the authors advocate ultra-early aggressive medical treatment for this subgroup of patients with orbito-frontal contusion, prior to dramatic clinical and radiographic deterioration, as the outcome difference could be great.

Adult

Primary cerebral leiomyosarcoma.

A case of a rare primary cerebral leiomyosarcoma in an 8-year-old male is described. The patient presented with a new-onset seizure disorder and was found to have a rapidly expanding left parietal extra-axial lesion, documented by radiological imagings. The patient underwent surgical resection of the leiomyosarcoma, as well as adjuvant radiotherapy and chemotherapy. He is still surviving to date in stable neurological condition. The clinical presentation, surgical procedure, pathological findings and post-operative clinical course will be reported. The possible etiology of this rare extra-axial neoplasm is discussed.

Brain Neoplasms