Decompressive bifrontal craniectomy provides a statistical advantage over medical treatment of intractable posttraumatic cerebral hypertension and should be considered in the management of malignant posttraumatic cerebral swelling. If the operation can be accomplished before the ICP value exceeds 40 torr for a sustained period and within 48 hours of the time of injury, the potential to influence outcome is greatest.

Adhesion molecules are known to be involved in white cell adherence to the endothelium and subsequent diapedesis and migration in which a role in initiation of tissue damage is postulated. The authors have demonstrated the elevation of three adhesion molecules, with severely elevated levels of E-selectin seen in patients who later develop vasospasm. A correlation with a role of vascular adhesion molecules in the pathogenesis of cerebral vasospasm is suggested.

The nonoperative management of patients with Types II and III fractures of the odontoid process consists of a prolonged course of cervical immobilization. The need for rigid fixation, demonstrated by the routine use of the halo vest in many institutions, has never been rigorously substantiated. We retrospectively analyzed our results with the nonsurgical management of odontoid fractures to ascertain whether cranial fixation affected overall outcome. Fifty-four patients managed at the University of Virginia Health Sciences Center, Charlottesville, VA, between 1976 and 1994 were studied. All 18 patients with Type III fractures (5 treated in the collar, 18 in the halo vest) demonstrated fracture healing and late stability. Among 36 individuals with Type II fractures, 20 were treated in the halo vest and 16 were managed in the Philadelphia collar or similar orthoses. The overall rate of late surgical intervention, the stability to flexion and extension, and the rate of bony fracture healing were not statistically different between the methods of immobilization. The rate of bony union was not significantly higher in the halo vest group (74 versus 53%), even though patients managed in the Philadelphia collar were significantly older than those in the halo vest (mean, 68 versus 44 yr). In general, nonsurgical management of Type III odontoid fractures was recommended, accompanied by use of a cervical orthosis. The determination of operative versus nonoperative treatment for Type II fractures was made on the basis of fracture anatomy, patient age, other associated injuries, and patient preference. The lack of a significant difference in the need for late surgical procedures or late instability, improved patient comfort with the cervical orthosis, and elimination of the risk of halo-related complications favored the use of the rigid cervical orthosis in the majority of these cases.

a,-Macroglobuhn receptor/low density hpoprotem receptor-related protein (cc,M-RILRP) IS a multi-functional cell-surface receptor that has been tmphcated m diverse physiologic processes In normal human brain, a,M-R/LRP IS expressed prmclpally by pyramldal neurons with locahzation to cell bodies and proximal processes By contrast, a,M-R/LRP 1s not present m either the cell bodies or processes of most normal macrogha (mcludmg astrocytes) In this mvestlgatlon, we studied the expression of a,M-FULRP m the brain, followmg tissue InJury or neoplastic transformation, by lmmunohistochemlstry Significantly increased a,M-R/LRP lmmunoreactivlty was ldentlfied m reactive astrocytes, mdlcatmg that expression of this receptor is regulated m viva m response to brain injury a2M-R/LRP lmmunoreactivlty was also detected m ghal cell tumors. this finding 1s novel since malignant transformation 1s typically thought to turn off expression of this receptor

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