A retrospective analysis of 76 civilian craniocerebral gunshot wounds treated over a 20-month period is presented. The authors report a 62% mortality rate and conclude that the admission Glasgow Coma Scale (GCS) score is a valuable prognosticator of outcome. Other important findings were: patients with a GCS score of 3 invariably died, with or without surgical intervention; and the presence of intracranial hematomas, ventricular injury, or bihemispheric wounding was associated with a poor outcome. Standardized methods of data reporting should be adopted in order to allow multicenter trials or comparisons that might lead to management practices that could improve results.
The advent of EC/IC Bypass surgery has focused attention on selected patients who might benefit from this innovative procedure. There is a poverty of natural history data pertaining to all such lesions. Two centres (Memphis, Tennessee and London, Ontario) pooled their resources to carry out a retrospective review of 58 patients with angiographically-proven intracranial internal carotid artery steno-sis. Only 33% of the patients were alive and free from subsequent cerebral vascular events at the end of the mean follow-up of 30 months. Forty-three percent of the patients died during follow-up: 36% due to stroke and 44% because of cardiac disease. Forty-three percent of the patients suffered cerebral vascular events during the follow-up period: there were 17 strokes (29%) including 9 fatal strokes. The incidence of ipsilateral stroke was 19%; 65% of the strokes were appropriate to the stenotic intracranial carotid lesion under study. The annual ipsilateral stroke rate for patients with this lesion was 7.6% per year. This lesion detected on angiography is indicative of severe atheroma, and carries a serious risk of death due to ischemic heart disease or stroke. Stroke Vol 13, No 6, 1982 ATHEROSCLEROTIC STENOSIS OF THE INTERNAL CAROTID ARTERY (ICA) is a common lesion, most frequently found in the cervical portion of the internal carotid artery just beyond its origin. Carotid endarterectomy is often performed in the management of patients with atheromatous irregularity, ulcerative disease and stenosis of this portion of the artery. Severe intracranial ICA stenosis is not as common and is usually found in the surgically inaccessible part of the artery between the carotid canal and the origin of the ophthalmic artery.' The advent of extracranial to intra-cranial (EC/IC) bypass surgery has focused attention on this lesion as one that might benefit from the innovative procedure. Review of this literature reveals a poverty of data on the natural history of such lesions. The natural history of 21 patients with symptomatic intracranial ICA stenosis from London, Ontario was reviewed and reported in an earlier communication. 2 Subsequently resources were pooled with Memphis, Tennessee to carry out a retrospective review and analysis of this lesion. Patients and Methods Patients were seen at University Hospital, London, Ontario between 1972 and 1980 and at the VA Hospital , Memphis, Tennessee between 1975 and 1981. Seventy-four patients formed the initial data base as judged by angiographic findings. Patients were included who had a stenosis reducing the arterial lumen by at least one-third of its diameter in one or both intracra-nial portions of the internal carotid arteries. Asympto-matic as well as symptomatic lesions were studied. Several patients had an ipsilateral lesion in the extra-cranial part of the artery (tandem lesion) and these were included. Also included were patients who had a cervical carotid endarterectomy. Patients were not included in this natural history review for the following From reasons: an EC/IC bypa...
Preliminary data have suggested that phenytoin systemic clearance may increase during initial therapy in critically ill patients. The objectives for this study were to model the time-variant phenytoin clearance and evaluate concomitant changes in protein binding and urinary metabolite elimination. Phenytoin was given as an intravenous loading dose of 15 mg/kg followed by an initial maintenance dose of 6 mg/kg/day in 10 adult critically ill trauma patients. Phenytoin bound and unbound plasma concentrations were determined in 10 patients and urinary excretion of the metabolite p-hydroxyphenyl phenylhydantoin (p-HPPH) was measured in seven patients for 7 to 14 days. A Michaelis-Menten one-compartment model incorporating a time-variant maximal velocity (Vmax) was sufficient to describe the data and superior to a conventional time-invariant Michaelis-Menten model. Vmax for the time-variant model was defined as V'max + Vmax delta (1 - e(-kindt)). Vmax infinity is the value for Vmax when t is large. The median values (ranges) for the parameters were Km = 4.8 (2.6 to 20) mg/L, Vmax infinity = 1348 (372 to 4741) mg/day, and kind = 0.0115 (0.0045 to 0.132) hr-1. Phenytoin free fraction increased in a majority of patients during the study period, with a binding ratio inversely related to albumin. Measured urinary p-HPPH data were consistent with the proposed model. A loading and constant maintenance dose of phenytoin frequently yielded a substantial, clinically significant fall in plasma concentrations with a pattern of apparently increasing clearance that may be a consequence of changes in protein binding, induction of metabolism, or the influence of stress on hepatic metabolic capacity.
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