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The history of five patients, having developed intraventricular bleeding following head injury, was reviewed. Only two patients survived, one of whom eventually lapsed into a persistent vegetative state. The only patient showing good recovery was an 8-year-old girl. Primary traumatic intraventricular hemorrhage should be considered a rare, but serious entity with a very poor prognosis.
Reports on the topography of SEPs in non-comatose patients have drawn attention to a second thalamo-cortical loop connecting the thalamus with the frontal cortex, which has a close anatomical relation to the fronto-limbic structures frequently damaged in severe head injury (SHI). We studied whether the frontal component (P20/22) of the somatosensory evoked response (SEP), known to be due to a generator different from that of the traditionally analysed parietal SEP component (N20), would be differently affected by SHI. Moreover, we examined whether its analysis would improve the prognostic evaluation in the Glasgow outcome scale (GOS) after 3-6 months. In 50 patients examined within 72 h after the injury we found a dissociated impairment of frontal and parietal components in 24% of the recorded SEPs. When both frontal and parietal components were used as predictors, discriminant analysis correctly classified 94% of the patients into good (GOS good recovery and moderate disability) or poor (GOS severe disability, persistent vegetative state or death) outcome groups. Classification was less accurate and misclassifications grosser when considering parietal or frontal parameters alone. Our results show that (i) the evaluation of frontal components provides information different from that of the parietal SEPs, confirming the presence of different generators, and (ii) a combined analysis of the two components improves the prognostic evaluation with regard to the global outcome.
Patients in coma and a persistent vegetative state (PVS) lack cognitive ability, but may survive for prolonged periods. They present their family members with complex and difficult questions with respect to their treatment and care ranging from the type of technical support they should receive to the nature of adjustments in daily life to accommodate new circumstances and needs. Such decisions are often made in the face of considerable socio-economic and moral constraints with little if any medical guidance and no firm cultural guidelines. Based on a continuing study of families of patients in coma and PVS living in the greater New York area and using the case-study method, this paper argues that such patients and their families find themselves in socially ambiguous and isolated positions which can best be described through the anthropological concept of liminality. Further, it is hypothesized that decisions concerning these patients will in part reflect the way in which family members define the concept of self.
Does legal defensiveness significantly influence physicians' assessments of medical futility, in ways that may adversely affect the rights of patients and their family members to make their own health care decisions at the end of life? This exploratory study addresses that question with attitudinal data from a survey of 301 physicians practicing in academic medical centers in Texas. The majority of respondents indicated that the probability of success defining futile treatment should hypothetically be lower for patients with potential to benefit more from life-sustaining medical intervention (e.g. typically patients who are sentient), and higher for patients with less potential to benefit (e.g. patients in a persistent vegetative state). That is to say, physicians normally perceive longer odds to be worth pursuing for greater potential gain - a position that seems logically consonant with patients' rational self-interest. However, physicians with an attitude of extreme legal defensiveness did not fit this pattern. Rather, they tended to define futility in a manner that would maximize the physician's latitude to justifiably oppose patient preferences for end-of-life treatment abatement. These findings suggest that some physicians assume an adversarial position in their consideration of medical futility issues - an attitude that anticipates conflict with terminally-ill patients or their surrogates. The analysis presented here is not definitive, but at least raises the question of whether some physicians may inappropriately use their prerogative over medical futility as a means to guard their professional autonomy against perceived threats.
A case of a young man who was a victim of strangulation is presented. He arrived at the hospital in refractory status epilepticus, controlled only with intravenous pentobarbital. The initial CT scan showed mild cortical edema. Two days later, a CT scan showed diffuse cortical swelling and bilateral basal ganglia infarcts. Upon discontinuation of pentobarbital therapy, his neurological examination revealed spontaneous ventilation and a gag reflex. A CT scan 4 weeks after the insult demonstrated hypodensities in both cerebral hemispheres and hydrocephalus. EEG was isoelectric throughout his hospitalization. He survived nearly 5 months and succumbed to pneumonia. Neuropathological examination demonstrated severe encephalomalacia, multiple cystic infarcts and generalized compensatory ventriculomegaly. Microscopic examination was particularly remarkable for a pronounced gemistocytic astrocyte proliferation in the white matter. This case illustrates the long-term neuropathological consequences of severe, global hypoxia/ischemia and the paucity of intact brain required to maintain a persistent vegetative state.
Medical records of all expired patients as well as all patients designated on billing logs as having received cardiopulmonary resuscitation (CPR) during a 6-month period were reviewed. Patients were considered to have been 'coded' if they were found unresponsive and if the advanced cardiac life support (ACLS) protocol of the American Heart Association (AHA) was subsequently initiated. Of 105 patients who received CPR, 98 died during their hospital stay. Of the seven remaining patients, four had undergone coronary by-pass graft surgery, one was discharged in a persistent vegetative state, one died during an admission 2 months later, and one patient was transferred to another institution where he died. Various factors were studied in an effort to determine how patients on whom resuscitation was attempted differed from those who died without ever having received CPR. Patients who underwent CPR at least once during their hospitalization were more likely to have had cardiac diagnoses on admission (P < 0.001), to have been postoperative (P = 0.02), to have been admitted to a monitored bed on admission (P < 0.001) to have received more days of intensive care (P < 0.001) and to have received more specialist consultations (P = 0.004). Patients not receiving CPR were more likely to have had a primary diagnosis of neoplastic disease (P < 0.001), stroke or intracranial hemorrhage (P = 0.02) or dementia (P < 0.001). Age, race, or gender did not differ significantly between the two groups.
AIM: To provide long term population-based follow up on major trauma patients 12 years after injury. METHODS: This cohort study was based on a stratified random sample of patients with an injury severity score greater than 15 who reached hospital alive in 1990-1991. The patient details were used to trace them and to assess the patients' recovery, using endpoints of current employment status and any current physical or mental health problems. A Glasgow outcome score was allocated on the basis of these replies. RESULTS: Of 239 patients included in the original tranche, (23.2/100,000), 165 (16/100,000) survived to hospital discharge. 138 (86%) were traced, and 4 patients had left the country. Patients mean age was 34 (range 2-93). The male to female ratio was approximately 3:1. Twenty-one patients had died since discharge, due to unrelated illnesses. One hundred and five (76%) were living independently (GOS 4 and 5). Eleven patients (8%) were severely disabled, requiring assistance with activities of daily living. One patient remains in a persistent vegetative state. Return to work rates for those working at time of injury (and who remain of employable age) was 90%. The unemployment rate in the study population who are of working age was 34% (pre-injury rate 13%). The unemployment rate for those injured before their 17th birthday is currently 52%. CONCLUSION: We now have 12 year population based outcome data for major trauma. Despite major injury, 90% of long term survivors are living independently, with 90% returning to work. There is a trend towards higher unemployment when injured in childhood.
This study investigated whether or not early electroencephalographic (EEG) findings and brain computed tomographic (CT) features reflect the prognosis of comatose patients for 48 h after cardiopulmonary resuscitation (CPR). EEGs and brain CT scans were collected from 21 patients within 72 h after CPR. The EEG findings were classified according to the five Hockaday grades. The Glasgow outcome scale (GOS) applied 3 months after CPR was used for prognosis. Of the nine patients with grade 1 and 2 EEGs, eight had a good outcome (five recovered satisfactorily and three remained moderately disabled). Of the eight patients with grade 4 and 5 EEGs, seven had a poor outcome (three died and four remained in a persistent vegetative state). On the other hand, there was no correlation between early CT features and prognosis except for two severe cases, one whose gray/white matter interface had disappeared and the other with relatively increased density of the thalami, brain stem and cerebellum. These findings suggest that EEG is more useful than CT scan as a diagnostic tool for anoxic encephalopathy after CPR.
Traumatic internal carotid artery dissection is a serious condition that may cause ischemic stroke in young patients. It has been under-diagnosed in the past. We present three cases of traumatic internal carotid artery dissection. The clinical manifestations include hemicrania, hemiparesis, partial Horner's syndrome and cranial nerve palsy. Diagnosis is with carotid color Doppler ultrasound, CT angiography of the neck and conventional angiography. The outcome may be poor with hemiparesis, persistent vegetative state and death. We review the literature and discuss the clinical presentation, diagnosis, grading and treatment choices for traumatic internal carotid artery dissection and stroke.
A stainless steel tube was used as an endoscope sheath in combination with a working channel endoscope to evacuate hypertensive putaminal intracerebral haematoma (ICH). A frontal entry point ipsilateral to the haematoma was selected for insertion of the sheath. From January to June 2004, seven patients with putaminal ICH underwent endoscopic surgery in our hospital. There were no surgical complications. Haematoma evacuation rates were greater than 90% (median of 93%). Six patients (87%) regained consciousness within one week. Six patients, including four who had no residual disability and two who had moderate disability, were able to function independently. One patient remained in a persistent vegetative state at clinical follow-up after 6 months. Use of a stainless steel endoscopic sheath combined with working channel endoscopy via a frontal approach facilitates evacuation of putaminal ICH.
There is controversy as to what extent the processing of spectrally rich sounds in the human auditory cortex is related to the processing of singular frequencies. An informative index of the function of the auditory cortex, particularly important in neurological patients, is the mismatch negativity (MMN), a component of auditory event-related potentials. In the present study the MMN was recorded in 79 patients with extremely severe diffuse brain injuries, most of them in persistent vegetative state or minimal consciousness state. Both sinusoidal ('pure') and complex musical tones were used. Different statistical approaches converged in that musical tones elicited an MMN significantly more frequently, and of a larger amplitude, than simple sine tones. This implies that using simple stimuli in clinical populations may lead to a severe underestimation of the functional state of a patient's auditory system. The findings are also in line with behavioral and physiological data indicating independent processing of complex sounds in the auditory cortex.
An electroencephalogram disclosing electrocerebral silence (ECS) after cardiopulmonary resuscitation (CPR) is usually considered an unfavorable prognostic indicator associated with brain death or persistent vegetative state. I report a case of a comatose patient following cardiac arrest, whose initial electroencphalography (EEG) was isoelectric taken 5 h after onset. Median somatosensory evoked potentials (SSEP) obtained immediately after the initial EEG were normal. He then underwent gradual recovery of neurologic function with incremental improvement on serial EEG study, and eventually achieved full neurological recovery. SSEP proved to be a more reliable predictor of a neurological outcome that was ultimately favorable.
OBJECTS: To analyze the relationship between stress hormones (arginine vasopressin (ADH), adrenocorticotropic hormone (ACTH) and cortisol and the outcome of patients resuscitated after cardiopulmonary arrest (CPA). METHODS: Thirty-six patients were enrolled in this study. In 36 of the resuscitated cases, 27 were non-survivors and 9 survived. The survival group was defined as cases either in a persistent vegetative state, with some disability or good recovery 1 month after return of spontaneous circulation (ROSC). The non-survival group was defined as cases who died within 1 month. RESULTS: The plasma ADH and ACTH levels and the serum cortisol levels in both the surviving and the non-surviving patients were 82.3+/-74.5 and 149.6+/-135.4 (pg/ml), 239.7+/-327.4 and 282.4+/-553.0 (pg/ml), 34.1+/-11.2 and 19.0+/-12.8 (g/ml) (mean+/-S.D., respectively). The plasma ADH and ACTH levels showed no significant difference between the two groups. The serum cortisol levels were significantly higher in survivors than in the non-survivors (P=0.029). We also used the receiving-operating characteristics (ROC) curves to evaluate the optimal cutoff value of the concentration of serum cortisol as a predictive maker of non-surviving patients. The cutoff value of 16.7 g/ml for the concentrations of serum cortisol was a 1.00 positive predictive value and a 1.00 specificity at a 0.519 negative predictive and a 0.409 sensitivity for predicting non-surviving patients. The area under the ROC curve was calculated to be 0.858 at a prevalence of 0.58. The plasma ADH levels correlated significantly and positively with the plasma ACTH levels (r=0.516, P<0.0010). CONCLUSIONS: We concluded that the serum cortisol levels were significantly higher in survivors than in non-survivors resuscitated after CPA.
While brain death and the dead donor rule (patients must not be killed by organ retrieval) have been clinically and legally accepted in the US as a prerequisite to organ removal, there is little data about public attitudes and beliefs concerning these matters. To examine the public attitudes and beliefs about the determination of death and its relationship to organ transplantation, 1351 Ohio residents >or=18 years were randomly selected and surveyed using random digit dialing (RDD) sample frames. The RDD telephone survey was conducted using computer-assisted telephone interviews. The survey instrument was developed from information provided by 12 focus groups and a pilot study of the questionnaire. Three scenarios based on hypothetical patients were presented: brain dead, in a coma, or in a persistent vegetative state (PVS). Respondents' provided personal assessments of whether the patient in each scenario was dead and their willingness to donate that patient's organs in these circumstances. Over 98% of respondents had heard of the term brain death, but only one-third (33.7%) believed that someone who was brain dead was legally dead. The majority of respondents (86.2%) identified the brain dead patient in the first scenario as dead, 57.2% identified the patient in a coma as dead (Scenario 2), and 34.1% identified the patient in a PVS as dead (Scenario 3). Nearly, a third (33.5%) were willing to donate the organs of patients they classified as alive for at least one scenario, in seeming violation of the dead donor rule. Most respondents were not willing to violate the dead donor rule, although a substantial minority was. However, the majority of respondents were unaware, misinformed or held beliefs that were not congruent with current definitions of brain death. This study highlights the need for more public dialogue and education about brain death and organ donation.
The purpose of this study was to evaluate prospectively short-latency somatosensory evoked potentials (SEPs) as a predictor of outcome in acute, severe brain injury, and to compare this with the predictive power of the motor component of the Glasgow Coma Scale score and computed tomographic scan. Outcome was measured with the Glasgow Outcome Scale at a minimum of 6 months after injury. We studied 109 patients (aged 0.1 to 16.8 years) with SEPs within 4 days of the onset of coma. Four patients had absent SEPs and a favorable outcome by the Glasgow Outcome Scale (full recovery or moderate disability); two of these patients had meningitis with bilateral subdural effusions, one had a midbrain hemorrhage, and one had a decompressive craniectomy for uncontrolled intracranial hypertension. Normal SEPs had a positive predictive value for favorable outcome of 93% (95% confidence interval (CI), 77% to 99%), and absent SEPs had a positive predictive value for unfavorable outcome by the Glasgow Outcome Scale (severe disability, survival in a persistent vegetative state, or death) of 92% (95% CI, 80% to 98%). If the above identifiable clinical situations in which a physical barrier existed to impede cutaneous reception of the electrical impulse were excluded, the positive predictive value of absent SEPs for poor outcome reached 100% (95% CI, 92% to 100%). An absent motor response to painful stimulus also had 100% positive predictive value (95% CI, 84% to 100%) for unfavorable outcome; however, 23% of patients could not be evaluated because of the effects of muscle relaxants or sedatives. In patients with traumatic brain injury, results of computed tomography did not reliably predict outcome. Of the 59 patients with unfavorable outcome, 76% could be identified with SEPs compared with 36% with examination of motor function. We suggest that SEPs be performed in children with acute severe brain injury because they add an important tool to the physician's prognostic armamentarium. We conclude that in the absence of the above mentioned identifiable clinical situations, absent SEPs predict 100% unfavorable outcome, and this finding may warrant consideration of withdrawal of treatment in children with brain injuries.
BACKGROUND: Orbital roof fractures after blunt injury are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 15 cases published to date. METHODS: The clinical, radiological, and surgical findings of 6 cases of traumatic encephalocele treated at our institution from June 1998 to January 2000 are presented. They are also compared with previously published series. RESULTS: In contrast to other published cases, 5 out of 6 patients in our series were adults. The most common cause of trauma was road traffic accident. Ecchymosis and preoperative exophthalmos/proptosis were frequent. In all of our patients a coronal CT scan (3 mm increments with bone windows) was obtained. It demonstrated the extension of the orbital roof fractures and a possible encephalocele in 4 cases. Associated frontal brain contusions were seen in 5 cases. An MRI was performed in 3 patients (and only in 2 previously published cases); it showed the extension of the brain herniation into the orbital cavity. Surgical treatment via a fronto-basal approach with evacuation of the contused herniated brain tissue and orbital roof reconstruction was performed. The outcome at 6 months was good recovery in five patients with one patient still in a persistent vegetative state. Postoperatively the ocular disturbances improved in 5 cases. A review of the other published cases confirmed recovery of normal ocular function in the vast majority of the cases. CONCLUSIONS: Whenever orbital roof fractures associated with frontal contusions are identified in an acute brain injured patient, an orbital encephalocele should be suspected. In our opinion MRI is the investigation of choice in such patients. If the encephalocele is confirmed, a surgical approach via the subfrontal route is indicated with resection of herniated contused brain tissue, dural closure, and orbital roof reconstruction. Good results in regard to the orbital symptoms (mainly exophthalmos) can be expected.
BACKGROUND: Although rare, patients with acute subdural hematoma (ASDH) because of severe head injury can develop contralateral acute epi- or subdural hematoma, requiring consecutive surgical procedures. The choice of treatment strategies for such patients is clinically important. METHODS: Among 88 patients with ASDH who were surgically treated over 13 years, we encountered and studied 5 patients who developed contralateral acute epi- or subdural hematoma (5.7%). RESULTS: All 5 patients were male, ranging in age from 17 to 40. According to the Glasgow Coma Scale on admission, 1 patient was rated 3, 1 was 4, 1 was 5, and 2 were 6. All patients underwent consecutive surgical procedures for ASDH and contralateral ASDH and/or acute epidural hematoma, and were given postoperative supportive therapy with barbiturates and mild hypothermia. Patients' outcomes according to the Glasgow Outcome Scale were as follows: 1 patient, good recovery (20.0%); 1, mild disability (20.0%); 2, severe disability (40.0%), and 1, persistent vegetative state (20.0%). No patients died. Although decompressive craniectomy and evacuation of hematoma may lead to contralateral acute epi- or subdural hematoma in patients with ASDH, this therapy is justified because hematoma irrigation with trephination therapy has a poor outcome for comatose patients. CONCLUSION: Awareness of intraoperative brain swelling is important, as it suggests the development of contralateral hematoma. Immediate computed tomography and a rapid return to the operating room are therefore critical.
Persisting disability after brain damage usually comprises both mental and physical handicap. The mental component is often the more important in contributing to overall social disability. Lack of an objective scale leads to vague and over-optimistic estimates of outcome, which obscure the ultimate results of early management. A five-point scale is described--death, persistent vegetative state, severe disability, moderate disability, and good recovery. Duration as well as intensity of disability should be included in an index of ill-health; this applies particularly after head injury, because many disabled survivors are young.