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Michael J. Rosner and Donald P. Becker

only minimally changed or even less than normal, and the ability of the mitochondria to metabolize the lactate reduced to a major degree? The latter seems the better alternative. The following is a speculative synthesis and serves as a theoretical framework for therapy directed at intracellular acidosis. Studies in the fluid-percussion model system in these laboratories using the 2-deoxyglucose technique for measuring uptake of glucose have demonstrated an overall reduction in the rate of glucose uptake, even though a few areas such as the inferior colliculus and

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Steven K. Gudeman, J. Douglas Miller and Donald P. Becker

I n the past 10 years glucocorticoid therapy has come to be used routinely in the management of patients with severe head injury. This has happened despite a disconcerting lack of evidence of its beneficial influence on outcome or on intracranial pressure (ICP) in such patients. This is in marked contrast to the application of steroid therapy in patients with chronic focal lesions, such as brain tumors or abscesses, that are associated with spreading, perifocal edema. 9, 10 In such patients clinical improvement ensues within hours of starting steroid therapy

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Theodore G. Obenchain and Donald P. Becker

of patients on intermittent methotrexate therapy may develop fever, headaches, dyspnea, and cyanosis. All patients so far described have had acute leukemia and bilateral interstitial pulmonary infiltrates on chest x-ray. This is a monophasic illness, probably with an allergic basis. It usually subsides with discontinuation of the medication. Our patient continued to complain of episodic headaches and fever for 7 months after the methotrexate was discontinued. She has remained free of symptoms since the abscess was excised. References 1. Asenjo

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Theodore G. Obenchain and Donald P. Becker

✓ A woman with hydrocephalus and head bobbing presented with headaches and episodic loss of consciousness. Contrast studies revealed a cyst within the third ventricle. At craniotomy it occupied the entire third ventricle and its walls merged with the hypothalamus. This is considered to be a congenital suprasellar arachnoid cyst which expanded superiorly through the third ventricle. Similar cases are reviewed and therapy briefly discussed.

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Stanley J. Goodman and Donald P. Becker

preparation was designed to study the natural progression of untreated intracranial hypertension produced by an expanded supratentorial mass. The only variable systematically altered was the peak supratentorial pressure attained at completion of the expansion procedure. Thereafter, we neither evacuated the mass nor supported vital functions, both of which maneuvers constitute forms of therapy. We specifically asked a number of interrelated questions. What are the brain-stem vascular changes in mass-induced intracranial hypertension? Do such changes correlate with the

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Donald P. Becker and Frank E. Nulsen

able to salvage two infected shunts with bacteremia using a combination of intravenous and intraventricular antibiotics via the Rickham reservoir. An operative infection rate in 1965 of three cases in 79 operations (4%) stemmed from one low catheter placement, one wound infection, and one Rickham reservoir erosion through scalp. It remains to be seen whether our present regime of prophylactic antibiotic therapy in association with each surgical intervention will further reduce this complication. 17 Late deaths in our series continue to occur at a rate of three per

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Philippe Gadisseux, John D. Ward, Harold F. Young and Donald P. Becker

stimulus for this response is poorly understood. It is now believed that catecholamines are the major calorigenic mediators. 7, 101, 199 One of the goals of nutritional therapy in injured patients is to meet these increased caloric requirements in order to avoid depletion of the body fuel stores. Protein Metabolism Protein metabolism after injury or surgery has been studied by two methods: measurement of nitrogen balance and determination of whole-body protein turnover rate. The nitrogen balance is the difference between daily nitrogen intake and daily nitrogen

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Alfred T. Nelson Jr., H. St. George Tucker Jr. and Donald P. Becker

studies underwent irradiation of the sella. The endocrine results presented in this paper were determined prior to the commencement of radiation therapy. Management of hormone replacement following surgery was guided by the patient's preoperative endocrine status and by whether normal gland was seen intraoperatively. If patients had normal pituitary function preoperatively and if 20% or more normal-appearing gland was visualized intraoperatively, then steroids were tapered over 3 days unless the patient showed signs of adrenal insufficiency. If patients were receiving

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Neurosurgical Forum: Letters to the editor To The Editor James S. Heiden , M.D. Martin H. Weiss , M.D. Los Angeles, California 491 493 Dr. Becker and co-workers claim that vigorous surgical and medical therapy in severe head injury has increased the survival and incidence of good outcome in patients comatose from head injury. This concept is enthusiastically supported. However, we take issue in comparing their seemingly effective approach against other published series, especially the Glasgow

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course from the rest in that group. The authors also point out the very important conclusion that “some patients with even the most gloomy combination of signs may do well if decompressive surgery is carried out early and followed by intensive therapy.” This conclusion may not be related only to head injuries but also to patients with impending “brain death.” It stresses the importance of being more careful in applying that diagnosis in patients with intracranial mass lesions of any cause compared with “diffuse brain injury” with generalized intracranial circulatory