The outcome in 53 children following severe head injury is presented. All children were graded using the Glasgow Coma Scale; 90% made a good recovery or were moderately disabled, and 8% died or were left vegetative. All patients were treated with controlled ventilation and steroids; mannitol, and, if necessary, Nembutal (pentobarbital) were used to maintain the intracranial pressure below 20 torr. With this regimen, only one death occurred due to uncontrollable intracranial hypertension. All patients with a coma scale of 5 or greater recovered well. The worst prognostic sign was the presence of flaccidity: 33% of these patients died or were vegetative. Five of seven patients who were decerebrate or flaccid with bilateral fixed pupils and absent caloric responses made a good recovery or were moderately disabled. The relatively low incidence of mass lesions (23%) and high incidence of diffuse cerebral swelling (34%) suggest a different pathophysiological response of the child's brain to injury, which may play a role in the improved survival of children following severe head injury when compared to adults.

The boundaries of somatosensory cortex were localized noninvasively by means of a large-array biomagnetometer in six patients with mass lesions in or near eloquent cortex. The results were used by neurosurgeons and neurologists in preoperative planning and for reference in the operating room. The magnetic source imaging (MSI) localizations from somatosensory evoked potentials were used to predict the pattern of phase reversals measurable intraoperatively on the cortical surface, providing a quantitative comparison between the two measures. The magnetic localizations were found to be predictive in all six cases, with the two sets of localizations falling within an 8-mm distance on average. Somatosensory localizations using MSI offer accuracy in localizing somatosensory cortex stereotactically and in depicting its relationship to lesions. Such data are valuable preoperatively in assessing the risks associated with a proposed surgical procedure and for optimizing subsequent minimum-risk surgical strategy.

No abstract

Cerebral vasospasm in the anterior circulation has been recognized as a significant factor in the sequelae of head injury; however, vertebrobasilar spasm resulting from trauma has received much less attention. In the past year we have observed six patients where spasm in the major vessels of the posterior circulation was primarily or in part responsible for the neurological deficit. In such cases, the neurological examination may suggest a supratentorial mass with herniation and, in three of our cases, burr holes or carotid angiography were performed first. However, in every instance neurological signs present on admission indicated primary brain-stem dysfunction. In each of the six cases vertebral angiography demonstrated significant spasm in either the vertebral or basilar arteries. Intracranial pressure was monitored in each of the six patients and did not exceed 25 mm Hg in any. In cases of head injury where the neurological examination indicates brain-stem dysfunction inconsistent with or after a supratentorial mass has been excluded, vertebral angiography may aid in the diagnosis and subsequent management of such patients.

A 20-year-old woman developed ataxia, extrapyramidal movements, myoclonus, and progressive dementia. Brain biopsy disclosed status spongiosus, diagnostic of Creutzfeldt-Jakob disease; this is the youngest spontaneous case ever reported. Creutzfeldt-Jakob disease can occur in young adulthood.

Learning deficits have been noted in children with acute leukemia given methotrexate (MTX) with and without cranial irradiation (RT) for prophylaxis. A rat model has been developed to assess treatment effects on learning. The test used was altered performance of a simultaneous discrimination task in a standard operant conditioning box, employing the mean number of days needed to score 80% correct responses as the criterion. An illustrative experiment distributed suckling rats among four groups: (1) 36 controls; (2) 14 cranial RT (1,000 R); (3) 14 MTX (5 mg/kg i.p.); (4) 36 RT+ MTX 24 h later, and (5) 12 undernourished controls (to match poor weight gain patterns of treated animals). Survivors were tested 10–12 weeks later: values for groups 1–5 in order were 3.9, 4.1, 4.7, 5.0 and 4.0 days. Only group 4 results were significantly different from group 1 (p = < 0.05).

No abstract

The methodology for continuous monitoring intracranial pressure (ICP) being presently employed in the Neurosurgery Service of the University of Pennsylvania is presented. The methods are intraventricular recording of ICP (IVP) and subarachnoid recording of ICP (SaP). The indications for employing either method are briefly presented. IVP is favored in those situations in which the lateral ventricles are enlarged and SaP is preferred in the cases of brain swelling or other situations in which there is a small ventricular system.