Articles: brain-injuries.
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Am J Phys Med Rehabil · Aug 1991
Case ReportsDelayed presentation of a carotid-cavernous sinus fistula in a patient with traumatic brain injury.
Carotid-cavernous sinus fistulas are rare complications of traumatic brain injury, facial trauma and postorthognathic surgery. A high level of clinical suspicion is necessary, particularly for patients who are unable to communicate, to establish the diagnosis. A case of delayed presentation of a carotid-cavernous sinus fistula after traumatic brain injury is presented. This case illustrates that early recognition of this disorder is crucial to prevent significant morbidity.
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The normal verbal and motor responses embodied in the standard Glasgow Coma Scale (GCS) are not achievable during the first few years of life. The recent literature contains numerous reports of attempts to devise scales of responses quantitating the conscious level in infants and young children, both for research purposes and as clinical guides; some of these scales incorporate items, e.g. brainstem reflexes, that are not included in the GCS. We have reported on a simple paediatric version of the GCS, which uses the standard scale with minor modifications in the verbal component, and sets realistic age-related normal responses. ⋯ Of 35 cases considered to be fully conscious at 6 h, 31 have made good recoveries and only 1 has suspected residual disabilities. The study suggests that the scale accords with the realities of neurological immaturity, and confirms that it can be used in routine paediatric practice. For comparative therapeutic trials, the conscious level in infants has limited value as an index of brain injury, and should be complemented by other indices, such as brainstem reflexes.
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The article discusses the total results of multifactorial analysis of observations over 16,000 children with isolated and more than 400 with combined craniocerebral trauma (CCT) in the light of the peculiarities of the child age and the current trends in studying the problem in the Soviet Union and other countries. From these standpoints, the author first gives a clinicomorphological characterization of CCT types in children, deals with the methods and prospects of objectivication of the evaluation of the severity of isolated and combined CCT, extracranial local injuries in polytrauma, totally determining the severity of the general condition and the efficacy and prognosis of the diagnostic and therapeutic measures. Original methods for quantitative evaluation of the degree of severity of the trauma, which were developed in the clinic, are described. ⋯ For this purpose, the author uses conventional designations for the main gradients of the pathophysiological reactions of the child's organism depending on the location and severity of the concrete damages and the general condition, making a coded recording of the diagnosis possible, which makes easier the sorting out and registration of the patients and orientation as regards the order in which aid should be given and the volume of the therapeutic and diagnostic programs with the use of computers. The patients were subjected to general clinical examination and laboratory tests, as well as special methods of examination (radiography, ultrasonic study, angiography, circulography, computed tomography, etc.). Importance was attached to the results of histological study and the reports of the forensic medical examination committee.
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Experience with 120 patients who incurred a gunshot wound to the head with dural penetration is presented. All of the patients were managed by a standard resuscitation protocol and assigned a clinical grade based on their level of consciousness both at the time of presentation and at 2 to 4 months after injury. Fifty patients (42%) underwent surgery. ⋯ Nine patients, however, who were not comatose at the time of admission died from potentially preventable causes. In 3 of these patients, a more aggressive diagnostic approach (including cerebral angiography) may have altered their ultimate outcome. An expeditious approach to the trauma victim with a comprehensive management scheme after injury may have altered the course in the remainder of these patients.
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Transtentorial herniation is an ominous finding in the patient with head injuries. We report our experience with 10 patients suffering from acute transtentorial herniation secondary to posttraumatic unilateral hemispheric swelling who were treated aggressively with temporal lobectomy. Eight patients were men and 2 were women. ⋯ In this series, the mortality rate was 30%, including a single patient who was neurologically stable but died from nonneurological injuries. Of the 7 survivors, 4 were functionally independent and 3 required minimal assistance with the activities of daily living. Aggressive, early decompression via complete temporal lobectomy may thus significantly improve the outcome in patients with transtentorial herniation accompanying posttraumatic hemispheric swelling and midline shift.