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S. Sam Finn, Sigurdur A. Stephensen, Carole A. Miller, Laura Drobnich and William E. Hunt

✓ Thirty-two patients with aneurysmal subarachnoid hemorrhage (SAH) were managed according to a protocol based on pain control and hemodynamic manipulation, monitored by an arterial line and Swan-Ganz catheter. Hemodynamic parameters were adjusted to four clinical situations. 1) For the unoperated patient with no neurological deficit, the regimen aims to maintain pulmonary wedge pressure (PWP) at 10 to 12 mm Hg, and the cardiac index (CI) and blood pressure (BP) at normal levels. 2) For the unoperated patient presenting with or developing neurological deficit, the PWP is increased until the deficit is reversed or the CI falls; the CI is high, and the BP normal. 3) For the postoperative patient with no neurological deficit, the PWP is maintained at 12 to 14 mm Hg, the CI is a high normal, and the BP is normal. 4) For the postoperative patient developing neurological deficit but showing no surgical complication on the computerized tomography scan, the PWP is increased until the deficit is reversed or the CI falls; the CI is high and the BP is increased with vasopressors if necessary.

Fourteen patients developed neurological deficits either preoperatively, postoperatively, or both. Neurological deficits were repeatedly reversed by increasing the PWP, as measured hourly. In several patients an optimal wedge pressure was determined, below which deficits would reappear. In one patient whose neurological deficit was reversed on several occasions by increasing the PWP, the optimal PWP rose after each episode until it reached 22 mm Hg.

Detailed event-related analysis of these patients' course illustrates these phenomena well. The optimal PWP varied from patient to patient, but ranged most frequently from 14 to 16 mm Hg. Meticulous monitoring of the patients' neurological status coupled with prompt correction of low PWP (assuming an adequate CI) has proven to be an effective way to prevent and reverse neurological deficits following aneurysmal SAH.

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Pediatric neck injuries

A clinical study

Stephen A. Hill, Carole A. Miller, Edward J. Kosnik and William E. Hunt

✓ This review of pediatric neck injuries includes patients admitted to Children's Hospital of Columbus, Ohio, during the period 1969 to 1979. The 122 patients with neck injuries constituted 1.4% of the total neurosurgical admissions during this time. Forty-eight patients had cervical strains; 74 had involvement of the spinal column; and 27 had neurological deficits. The injuries reached their peak incidence during the summer months, with motor-vehicle accidents accounting for 31%, diving injuries and falls from a height 20% each, football injuries 8%, other sports 11%, and miscellaneous 10%.

There is a clear division of patients into a group aged 8 years or less with exclusively upper cervical injuries, and an older group with pancervical injuries. In the younger children, the injuries involved soft tissue (subluxation was seen more frequently than fracture), and tended to occur through subchondral growth plates, with a more reliable union than similar bone injuries. In the older children, the pattern and etiology of injury are the same as in adults. The entire cervical axis is at risk, and there is a tendency to fracture bone rather than cartilaginous structures.

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Carole A. Miller, Richard C. Dewey and William E. Hunt

✓ The authors describe a lumbar spine fracture that is characterized on anteroposterior x-ray views by separation of the pedicular shadows. It is almost invariably associated with posterior interlaminar herniation of the cauda equina through a dorsal dural split, and anterolateral entrapment or amputation of the nerve root. The fracture is unstable and requires internal fixation and fusion at the time of neurolysis. Fractures meeting these criteria should be explored as soon as the patient's condition permits. Myelography is usually unnecessary and may be contraindicated in some cases. The postulated mechanism of injury is hyperextension with vertical impaction and rupture of the ring made up of the lamina, pedicle, and vertebral body. The ring is fractured in several places in a manner similar to that seen in “Jefferson fracture” of C-1. The special anatomical relationships of the thoracolumbar junction and the plane of the lumbar facets are also discussed.

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John E. McGillicuddy, Glenn W. Kindt, James E. Raisis and Carole A. Miller

✓ A marked increase in intracranial pressure (ICP) produces a concomitant increase in systemic blood pressure (the Cushing response). In this study a comparison is made between this response of systemic blood pressure to increased ICP and the blood pressure responses produced by ischemia, hypoxia, and hypercarbia of the primate brain. A carotid-to-carotid cross-perfusion system was used to produce a purely cerebral hypoxia and hypercarbia. Each stimulus, except hypercarbia, produced a hypertensive response that was qualitatively and quantitatively similar. These responses were characterized by a short latent period, a rapid development, and an increase in mean arterial pressure of 60% or more. The similarity of the responses suggests that these stimuli act through a final common pathway independent of the purely mechanical effects of increased ICP upon the brain.

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J. Eric Zimmerman, Farhad Afshar, William Friedman and Carole A. Miller

✓ The authors describe a posterior compartment syndrome of the thigh and sciatic nerve palsy following a traumatic hematoma, and discuss its treatment.

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James E. Raisis, Glenn W. Kindt, John E. McGillicuddy and Carole A. Miller

✓ Cerebral metabolism in 21 hydrocephalic patients was studied. Preoperative and postoperative specimens of cerebrospinal fluid (CSF) were obtained and the cerebral perfusion pressure (CPP) was calculated in each instance. The specimens of CSF were analyzed for lactate and pyruvate and the lactate/pyruvate (L/P) ratio was calculated for each sample. The L/P ratio, which reflects the redox state of the cell, was used to determine the extent of anaerobic metabolism. An inverse relationship was noted between CPP and lactate as well as the L/P ratio. In general, the level of anaerobic metabolism was decreased after insertion of a shunt.

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James L. McGauley, Carole A. Miller and John A. Penner

✓ The authors report the development of diffuse intravascular coagulation following massive cerebral trauma in a child. The importance of anticipating this complication is stressed and recommendations for early diagnosis and treatment are presented.

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Floyd L. Haar and Carole A. Miller

✓ The authors report an unusual case of superior vena cava thrombosis in an infant who subsequently developed communicating hydrocephalus; they also review previously reported cases of dural sinus hypertension, and separate them into two groups. Patients in the first group develop hydrocephalus and those in the second develop a pseudotumor-like syndrome. The former patients tend to have generalized increase in intracranial venous pressure while the latter have a normal pressure in some major intracranial venous structure(s). The absence of venous cushioning of the choroid plexus pulse wave is proposed as the cause of ventricular enlargement in the former group. In addition, patients in the large-ventricle group were younger than patients in the small-ventricle group.