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Anne Laurent-Vannier, Caroline Rambaud and Harvey S. Levin

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Harvey S. Levin, Robert G. Grossman, James E. Rose and Graham Teasdale

✓ Long-term recovery from severe closed head injury was investigated in predominantly young adults whose Glasgow Coma score was 8 or less at the time of admission. Of the 27 patients studied (median follow-up interval of 1 year), 10 attained a good recovery, 12 were moderately disabled, and five were severely disabled. In contrast to previous studies suggesting that intellectual ability after severe closed head injury eventually recovers to a normal level, our findings showed that residual intellectual level, memory storage and retrieval, linguistic deficit, and personal social adjustment corresponded to overall outcome. All severely disabled patients and several moderately disabled patients exhibited unequivocal cognitive and emotional sequelae after long follow-up intervals. Analysis of persistent neuropsychological deficit in relation to neurological indices of acute injury severity demonstrated the prognostic significance of oculovestibular deficit.

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Harvey S. Levin, David H. Williams, Michael Valastro, Howard M. Eisenberg, Marsha J. Crofford and Stanley F. Handel

✓ To investigate evidence for diffuse white matter injury and hemispheric disconnection sequelae after severe closed head injury (CHI), this study evaluates the degree of posttraumatic atrophy of the corpus callosum. Corpus callosal atrophy was quantitatively determined using a digitizer to measure sagittal magnetic resonance images of 32 patients with moderate-to-severe CHI and those of 31 control subjects of similar age. In the CHI patients, measurements were significantly reduced for the areas of the anterior four-fifths, the posterior one-fifth, and the total corpus callosum. Moreover, the minimum width of the callosal body was reduced in the CHI patients as compared to that of control individuals. Indices of corpus callosal atrophy were significantly correlated with the chronicity of injury and the degree of lateral ventricular enlargement. There was no difference in callosal measurements between men and women. Magnetic resonance imaging provides an in vivo determination of corpus callosal atrophy which may reflect the severity of diffuse axonal injury and predict the type and severity of hemispheric disconnection effects.

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Harvey S. Levin, Stephen C. Lippold, Arnold Goldman, Stanley Handel, Walter M. High Jr., Howard M. Eisenberg and David Zelitt

✓ In a prospective investigation of neurobehavioral functioning in young boxers, 13 pugilists and 13 matched control subjects underwent tests of attention, information-processing rate, memory, and visuomotor coordination and speed. The results disclosed more proficient verbal learning in the control subjects, whereas delayed recall and other measurements of memory did not differ between the two groups. Reaction time was faster in the boxers than in the control subjects, but no other differences were significant. Ten subjects in each group were retested 6 months later and exhibited improvement in their neuropsychological performance as compared to baseline measurements. However, there were no differences in scores between the boxers and the control subjects at the follow-up examination or in the magnitude of improvement from baseline values. Magnetic resonance imaging, which was performed in nine of the boxers, disclosed normal findings.

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Harvey S. Levin, Steven Mattis, Ronald M. Ruff, Howard M. Eisenberg, Lawrence F. Marshall, Kamran Tabaddor, Walter M. High Jr. and Ralph F. Frankowski

✓ The majority of hospital admissions for head trauma are due to minor injuries; that is, no or only transient loss of consciousness without major complications and not requiring intracranial surgery. Despite the low mortality rate following minor head injury, there is controversy surrounding the extent of morbidity and the long-term sequelae. The authors postulated that consecutively admitted patients who fulfilled research diagnostic criteria for minor head injury and who were carefully screened for antecedent neuropsychiatric disorder and prior head injury would exhibit subacute cognitive and memory deficits that would resolve over a period of 1 to 3 months postinjury. To evaluate this hypothesis, the neurobehavioral functioning of 57 patients was compared within 1 week after minor head injury (baseline) and at 1 month postinjury with that of 56 selected control subjects at three medical centers. Quantified tests of memory, attention, and information-processing speed revealed that neurobehavioral impairment demonstrated at baseline by all means of measurement generally resolved during the first 3 months after minor head injury. Although nearly all patients initially reported cognitive problems, somatic complaints, and emotional malaise, these postconcussion symptoms had substantially resolved by the 3-month follow-up examination. The data suggest that a single uncomplicated minor head injury produces no permanent disabling neurobehavioral impairment in the great majority of patients who are free of preexisting neuropsychiatric disorder and substance abuse.

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Harvey S. Levin, Eugenio Amparo, Howard M. Eisenberg, David H. Williams, Walter M. High Jr., Craig B. McArdle and Richard L. Weiner

✓ Twenty patients admitted for minor or moderate closed-head injury were studied to investigate the relationship between magnetic resonance imaging (MRI) and neurobehavioral sequelae. The MRI scans demonstrated 44 more intracranial lesions than did concurrent computerized tomography (CT) scans in 17 patients (85%); most of these lesions were located in the frontal and temporal regions. Estimates of lesion volume based on MRI were frequently greater than with CT; however, MRI disclosed no additional lesions that required surgical evacuation. Neuropsychological assessment during the initial hospitalization revealed deficits in frontal lobe functioning and memory that were related to the size and localization of the lesions as defined by MRI. Follow-up MRI and neuropsychological testing at 1 month (13 cases) and 3 months (six cases) disclosed marked reduction of lesion size paralleled by improvement in cognition and memory. These findings encourage further investigation of the prognostic utility of MRI for the clinical management and rehabilitation of mild or moderate head injury.

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Guy L. Clifton, Christopher S. Coffey, Sierra Fourwinds, David Zygun, Alex Valadka, Kenneth R. Smith Jr., Melisa L. Frisby, Richard D. Bucholz, Elisabeth A. Wilde, Harvey S. Levin and David O. Okonkwo

Object

The authors hypothesized that cooling before evacuation of traumatic intracranial hematomas protects the brain from reperfusion injury and, if so, further hypothesized that hypothermia induction before or soon after craniotomy should be associated with improved outcomes.

Methods

The National Acute Brain Injury Study: Hypothermia I (NABIS:H I) was a randomized multicenter clinical trial of 392 patients with severe brain injury treated using normothermia or hypothermia for 48 hours with patients reaching 33°C at 8.4 ± 3 hours after injury. The National Acute Brain Injury Study: Hypothermia II (NABIS:H II) was a randomized, multicenter clinical trial of 97 patients with severe brain injury treated with normothermia or hypothermia for 48 hours with patients reaching 35°C within 2.6 ± 1.2 hours and 33°C within 4.4 ± 1.5 hours of injury. Entry and exclusion criteria, management, and outcome measures in the 2 trials were similar.

Results

In NABIS:H II among the patients with evacuated intracranial hematomas, outcome was poor (severe disability, vegetative state, or death) in 5 of 15 patients in the hypothermia group and in 9 of 13 patients in the normothermia group (relative risk 0.44, 95% CI 0.22–0.88; p = 0.02). All patients randomized to hypothermia reached 35°C within 1.5 hours after surgery start and 33°C within 5.55 hours. Applying these criteria to NABIS:H I, 31 of 54 hypothermia-treated patients reached a temperature of 35°C or lower within 1.5 hours after surgery start time, and the remaining 23 patients reached 35°C at later time points. Outcome was poor in 14 (45%) of 31 patients reaching 35°C within 1.5 hours of surgery, in 14 (61%) of 23 patients reaching 35°C more than 1.5 hours of surgery, and in 35 (60%) of 58 patients in the normothermia group (relative risk 0.74, 95%, CI 0.49–1.13; p = 0.16). A meta-analysis of 46 patients with hematomas in both trials who reached 35°C within 1.5 hours of surgery start showed a significantly reduced rate of poor outcomes (41%) compared with 94 patients treated with hypothermia who did not reach 35°C within that time and patients treated at normothermia (62%, p = 0.009).

Conclusions

Induction of hypothermia to 35°C before or soon after craniotomy with maintenance at 33°C for 48 hours thereafter may improve outcome of patients with hematomas and severe traumatic brain injury. Clinical trial registration no.: NCT00178711.

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Lawrence F. Marshall