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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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Methylprednisolone and neurological function 1 year after spinal cord injury

Results of the National Acute Spinal Cord Injury Study

Michael B. Bracken, Mary Jo Shepard, Karen G. Hellenbrand, William F. Collins, Linda S. Leo, Daniel F. Freeman, Franklin C. Wagner, Eugene S. Flamm, Howard M. Eisenberg, Joseph H. Goodman, Phanor L. Perot Jr., Barth A. Green, Robert G. Grossman, John N. Meagher, Wise Young, Boguslav Fischer, Guy L. Clifton, William E. Hunt and Nathan Rifkinson

✓ A multi-center double-blind randomized clinical trial was conducted by the National Acute Spinal Cord Injury Study Group to examine the efficacy of high-dose methylprednisolone (1000-mg bolus and 1000 mg daily thereafter for 10 days) compared with that of a standard dose (100-mg bolus and 100 mg daily for 10 days). No significant difference was observed in neurological recovery of motor function, pinprick response, or touch sensation 1 year after injury between the two treatment groups, after adjustment for other potentially confounding factors. Analyses that specifically took into account the patients' total steroid dose and relative weight confirmed the lack of a steroid treatment effect. The case fatality rate was 10.7% during the 1st year after injury, and this was not associated with the steroid treatment protocol or the patient's gender. Deaths did occur significantly more frequently among patients who were completely (15.3%) and partially (8.6%) plegic than among those who were paretic (2.5%, p = 0.0005), and among patients aged 50 years or older (38.6%, p = 0.0001).

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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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Stephen A. Hill, James M. Falko, Charles B. Wilson and William E. Hunt

✓ Hyperthyroidism due to thyrotrophin (TSH)-secreting pituitary tumors is rare. Four cases are described, with the features that allow preoperative diagnosis. In all the patients, thyroid hormone production was consistently elevated despite antithyroid therapy, and TSH levels were inappropriately elevated. All patients were treated with both surgery and irradiation. Each patient had recurrent tumor with suprasellar, intrasphenoidal, or intraorbital spread. The combination of a recurrent, aggressive tumor complicated by thyrotoxicosis makes this a complex and difficult surgical problem.

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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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Stephen Hill, Edward Martin, E. C. Ellison and William E. Hunt

✓ Carcinoembryonic antigen (CEA) was measured in plasma and cerebrospinal fluid (CSF) in patients with neoplasms and non-neoplastic neurologic conditions of the central nervous system (CNS). Seventy-two control patients had a mean CEAcsf of 0.04 ng/cu cm, 31 patients with benign tumors had a mean CEAcsf of 0.03 ng/cu cm, and 21 patients with malignant CNS tumors had mean CEAcsf of 21.7 ng/cu cm. In the absence of intradural metastasis, the existence of non-CNS malignancies did not cause CEA to appear in the CSF. There was no relationship between the plasma and CSF levels of CEA. The CSF is normally free of CEA, and its detection is strongly suggestive of either primary or secondary intradural malignancy. The titres of CEA decline with effective therapy, and may be of use in monitoring treated patients for recurrence.

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Carole Miller, Thomas V. Lloyd, John C. Johnson and William E. Hunt

✓ The authors present an unusual case of eosinophilic granuloma arising in the region of the foramen rotundum.

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Michael D. Walker, Eben Alexander Jr., William E. Hunt, Collin S. MacCarty, M. Stephen Mahaley Jr., John Mealey Jr., Horace A. Norrell, Guy Owens, Joseph Ransohoff, Charles B. Wilson, Edmund A. Gehan and Thomas A. Strike

✓ A controlled, prospective, randomized study evaluated the use of 1,3-bis(2-chloroethyl)-l-nitrosourea (BCNU) and/or radiotherapy in the treatment of patients who were operated on and had histological confirmation of anaplastic glioma. A total of 303 patients were randomized into this study, of whom 222 (73%) were within the Valid Study Group (VSG), having met the protocol criteria of neuropathology, corticosteroid control, and therapeutic approach. Patients were divided into four random groups, and received BCNU (80 mg/sq m/day on 3 successive days every 6 to 8 weeks), and/or radiotherapy (5000 to 6000 rads to the whole brain through bilateral opposing ports), or best conventional care but no chemotherapy or radiotherapy. Analysis was performed on all patients who received any amount of therapy (VSG) and on the Adequately Treated Group (ATG), who had received 5000 or more rads radiotherapy, two or more courses of chemotherapy, and had a minimum survival of 8 or more weeks (the interval that would have been required to have received either the radiotherapy or chemotherapy). Median survival of patients in the VSG was, best conventional care: 14 weeks (ATG: 17.0 weeks); BCNU: 18.5 weeks (ATG: 25.0 weeks); radiotherapy: 35 weeks (ATG: 37.5 weeks); and BCNU plus radiotherapy: 34.5 weeks (ATG: 40.5 weeks). All therapeutic modalities showed some statistical superiority compared to best conventional care. There was no significant difference between the four groups in relation to age distribution, sex, location of tumor, diagnosis, tumor characteristics, signs or symptoms, or the amount of corticosteroid used. An analysis of prognostic factors indicates that the initial performance status (Karnofsky rating), age, the use of only a surgical biopsy, parietal location, the presence of seizures, or the involvement of cranial nerves II, III, IV, and VI are all of significance. Toxicity included acceptable, reversible thrombocytopenia and leukopenia.