British journal of neurosurgery
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Percivall Pott (1714-1788) was an astute and prolific mid-eighteenth century English surgeon with a strong interest in head injury. He was partial to the use of the trephine for all skull fractures and favoured early exploratory trephination when an intracranial collection could not be ruled out. If haemorrhage or abscess was beneath the dura, it was incised. ⋯ The Atlantic breezes were believed beneficial to recovery. The operation of early 'preventive' trephination continued in the Cornish mining districts through the 1870s, when antiseptic methods were gradually adopted as elsewhere in England. Head injuries in miners became less common as mining reforms were introduced and head protection improved.
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The role of urgent surgery in improving the outcome of cauda equina compression following lumbar central disc prolapse remains controversial. Some series claim improved outcome from emergency decompression whilst others have found no benefit. Resolution of this issue is important because the opportunity to reverse neurological impairment may already have been lost by the time of hospital admission. ⋯ When performed under less than optimal conditions, as often exists in the emergency setting, surgery may even add to rather than alleviate morbidity. This article reviews the pathophysiology of cauda equina syndrome, its definition, and the controversies surrounding management. Where urinary retention with overflow incontinence extists at presentation we believe that urgent decompression confers no benefit.
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We report a unique case of a self-inflicted brain injury using an ingenious home-made gun with spontaneous anterior migration of the intact bullet. On admission, the patient was fully conscious with no neurological deficits. Computed tomography (CT) confirmed a penetrating missile injury with transventricular across midline trajectory and multi-lobe injury with the bullet lodged in the occipital lobe. ⋯ The patient experienced good outcome. Home-made gun injuries, although uncommon today, represent a special form of missile injury with unique low velocity terminal ballistics. As these weapons are seen infrequently today, surgeons should be alerted to their existence as patients with this form of injury usually have a good prognosis if vital brain structures are spared.
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Brain injury is known to result in various degrees of disordered haemostasis. Moreover, the recently developed assays of molecular markers of haemostasis can give an accurate reflection of its activation in vivo. The aim of this study was to monitor the levels of prothrombin fraction 1 + 2 (F1 + 2), thrombin antithrombin complexes (TAT) and D-dimer on the admission of patients to the ICU and up to the fourth day postinjury. ⋯ Haemostatic measurements could not predict good outcome (12 patients) or bad outcome (four deaths). It was concluded that haemostatic activation is a transient, but common phenomenon after head injury and is more prominent in cerebrovascular than in peripheral blood. The number of patients studied is too small to allow reliable association to be drawn between haemostatic changes on admission and prediction of outcome.