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John S. Tytus and Arthur A. Ward Jr.

✓ Two patients with giant aneurysms of the internal carotid artery showed progressive visual field deficits, and one, endocrine dysfunction. Neither patient had ever had symptoms suggesting subarachnoid hemorrhage. Both patients benefitted from common carotid ligation. Comparable reports are reviewed, and the application of a previously reported technique for monitoring gradual occlusion of the common carotid artery is emphasized.

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John T. Bonner and Arthur A. Ward Jr.

✓ A case of vertex epidural hematoma was satisfactorily diagnosed and treated by twist drill aspiration. It is suggested that this method may occasionally be preferable to craniotomy for this lesion.

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Franklin M. Epstein, Kevin R. Cooper and John D. Ward

✓ Hypoxemia is a nearly constant accompaniment of head injury. Diverse theories have been proposed to explain this relationship. The authors report the case of a patient who suffered an episode of severe, transient, arterial oxygen desaturation during “controlled” brain trauma: an otherwise uneventful stereotaxic biopsy of a small germinoma of the hypothalamus. Evidence is provided that pure ventilation-perfusion mismatching, without pulmonary edema, underlay the hypoxemia. The hypothalamus is intimately involved in matching pulmonary ventilation to perfusion; the hypoxemia of various brain injuries may be mediated by perturbation of this structure.

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Sung C. Choi, John D. Ward and Donald P. Becker

✓ An analysis of clinical and demographic data of 264 patients with severe head injury showed that a combination of the Glasgow Coma Scale (GCS) score, oculocephalic responses, and age can provide a simple but reliable prediction of outcome in severe head injury. Addition of other clinical data, excluding intracranial pressure and evoked potentials, improved the predictability only negligibly. A simple chart, which is constructed from the application of the logistic regression model, can be used to determine the odds of a good outcome from the combination of the three factors. A method is given by which the GCS score of a patient with a missing verbal response score can be accurately approximated in order to complete the chart. Among other values, the odds of a good outcome provide the clinician with a reliable measure of the relative severity of a patient's injury. The accuracy of the chart in prediction is expected to be 80% or above.

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Sung C. Choi, Raj K. Narayan, Randy L. Anderson and John D. Ward

✓ Data from 523 patients admitted to the Medical College of Virginia with severe head injury and known 6-month outcomes were analyzed in order to determine the optimal combination of early-available prognostic factors. Twenty-one prognostic indicators noted in the emergency room at admission were used to predict outcomes into four categories: good, moderately disabled, severely disabled, or vegetative/dead. A combination of the patient's age (in years), the best motor response (graded in the usual six-point scale), and pupillary response (in both eyes) was found to be the most accurate indicator. The model correctly predicted outcome into one of the four outcome categories in 78% of cases (“specifically accurate predictions”). If predictions into an outcome category adjacent to the actual outcome were accepted, this model was accurate in 90% of cases (“grossly accurate predictions”). A set of three simple graphs based on this model can be used for rapid early estimation of probable outcome in a severely head-injured patient at admission.

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

✓ There has been a rapid expansion of knowledge in the field of nutrition and metabolism with regard to the general surgical patient. However, only recently has there been greater appreciation of the benefits of adequate nutrition and appropriate metabolic care of the neurosurgical patient. In this review, the authors attempt to outline 1) the metabolic response to stress in general, and how it applies to the neurosurgical patient; 2) how best to provide adequate nutritional support for the neurosurgical patient; 3) the effects of nutrition on neurotransmitters; and 4) the effect of diet and nutrition on patients with malignant brain tumors.

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John D. Loeser, Arthur A. Ward Jr. and Lowell E. White Jr.

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Ann M. Ritter, Barbara H. Amaker, R. Scott Graham, William C. Broaddus and John D. Ward

✓ Leiomyosarcomas (LMSs) of the central nervous system are extremely rare; however, they are becoming more prevalent in immunocompromised patients. The authors present the cases of two patients with acquired immunodeficiency syndrome: one with LMS of the thoracic vertebral body and the other with LMS originating from the region of the cavernous sinus. The epidemiological and histological characteristics of LMS and its association with latent Epstein—Barr virus are discussed, as well as the treatments for this neoplasm.