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Michael L. Levy

In an attempt to assess admission Glasgow Coma Scale (GCS) scores and other radiographic variables after penetrating craniocerebral injury in relationship to outcome, the author evaluated a series of 294 patients with penetrating injuries who presented with a GCS score of 6 to 15 over a 6-year period. Entrance criteria required a replicable neurological examination that was not altered by the presence of hypotension, drugs/toxins, or systemic injury. All patients underwent surgical intervention and aggressive perioperative management, including resuscitative protocols, in the neurosurgical intensive care unit.

The author previously devised prospective models of outcome remained unchanged in this series. The variables most predictive of death include admission GCS score and subarachnoid hemorrhage in one model and admission GCS score and pupillary changes in a second when pupillary response was definitive at admission (p ≤ 0.00005). Other important variables related to morbidity include admission GCS, bihemispheric injury when associated with intraventricular hemorrhage, and diffuse fragmentation (p ≤ 0.001).

In this study a significant relationship between operative intervention and survival (p ≤ 0.01) was found in patients with an admission GCS scores of 6 to 8. No significant relationships between operative intervention and survival were found in patients with admission GCS scores of 9 to 12 and 13 to 15. A significant relationship between operative intervention and morbidity (p ≤ 0.01) was also demonstrated in patients with an admission GCS score of 12 to 15. No significant relationships between operative intervention and morbidity were found in patients with an admission GCS score of 6 to 8 and 9 to 12.

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Michael L. Levy and Steven L. Giannotta

✓ The effect of hypervolemic preload enhancement on cardiac performance was systematically analyzed in nine patients following aneurysmal subarachnoid hemorrhage. The patients ranged in age from 34 to 63 years, and none had a history of cardiac disease. Each patient underwent placement of a flow-directed balloon-tipped catheter and the following measurements were taken during hypervolemic therapy: pulmonary artery wedge pressure (PAWP), central venous pressure (CVP), cardiac index (CI), stroke volume index (SVI), and left ventricular stroke work index (LVSWI). After baseline measurements were recorded, hetastarch or plasmanate was infused intravenously at 300 cc/hr. Thermal output determination and pressures were measured every 15 minutes. The PAWP did not correlate in a statistically significant fashion with the CVP in the ranges recorded; however, a statistically significant correlation did exist between PAWP increases and increases in CI, SVI, and LVSWI (p < 0.01). There was no statistical correlation between PAWP increases above 14 mm Hg and improvement in cardiac performance as evidenced by CI, SVI, and LVSWI measurements. It is concluded that CVP is an unreliable index of cardiac performance during hypervolemic therapy and that, in previously healthy individuals, a PAWP of 14 mm Hg is associated with maximum cardiac performance.

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Michael L. Levy, Thomas C. Chen and Martin H. Weiss

✓ A case report of monostotic fibrous dysplasia of the clivus in a postadolescent woman is described. Although fibrous dysplasia of craniofacial structures is well documented, involvement of the clivus has not been reported. Diagnosis by clinical, radiographic, and histopathological features is detailed. Implications for the role of surgery and management are discussed.

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Michael L. Levy, Robert C. Granville, David Hart and Hal Meltzer

Object. The objective of this retrospective review was to identify patients on the pediatric neurosurgical ward with deep venous thrombosis (DVT) to develop diagnostic and treatment-related guidelines.

Methods. The authors performed a retrospective chart review of all cases of DVT presenting to the Children's Hospital between March 1986 and February 1997. Of 32 patients identified, 14 were followed by the neurosurgical service. Current records were additionally evaluated to assess follow-up condition in the patients as well as outcome. Variables included diagnosis, race, age, follow-up duration, outcome, presenting signs/symptoms, involved vessel(s), concurrent disease, diagnostic modalities, and treatment.

Patient age ranged from 1 to 16 years (mean 12.6 years, median 15 years). There were five girls and nine boys. Eight DVTs were right sided and six were left sided. Presenting symptoms included swelling of the affected extremity in 11 patients, pain in five, erythema in one, and cardiopulmonary arrest in two. Comorbidities included previous orthopedic procedures in three, brain tumors in two, and sepsis, fracture, pulmonary disease, preexisting coagulation disorders, and brain abscess in one patient each. Eight patients presented with a history of trauma. Two patients had undergone chemotherapy. Diagnostic studies included ultrasonography and venography in one, venography alone in two, computerized tomography (CT) scanning and venography in one, tagged red blood cell studies in one, ultrasonography and CT scanning in one, and ultrasonography alone in eight. In one patient an inferior vena cava filter was placed and one patient was treated with oral warfarin alone. One patient with a brain tumor died while hospitalized. In four patients there was evidence of rheumatological disease in the group of patients not treated neurosurgically. Two patients suffered recurrences during the follow-up period (mean 20 months)In the entire series of 32 patients there were five total deaths. Of these, two patients experienced six recurrences each, and one other patient suffered four recurrences. Of note, none of the recurrences was observed in patients with underlying coagulation disorders.

Conclusions. Children with DVT can experience serious complications in the form of both morbidity and mortality. Although most thrombotic complications have been found in patients with femoral lines, prolonged treatment involving a central line has been found to be a significant predictor of DVT. Multiple treatment modalities currently exist for children with DVT. Low-molecular weight heparin therapy has many benefits over unfractionated heparin agents and may be more appropriate for the prophylaxis or treatment of children and adolescents with DVT because of its acceptable safety and efficacy. Clinical data for neonates and young children remain incomplete.

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K. Anthony Kim, Michael Y. Wang, Pamela M. Griffith, Susan Summers and Michael L. Levy

The authors conducted a study to describe the incidence and types of fall-related head injury observed at a pediatric trauma center.

We performed a retrospective analysis of all patients under 15 years of age treated for fall-related trauma between 1992 and 1998. Falls were classified as low (< 15 feet) and high level (≥ 15 feet).

Seven hundred twenty-nine cases were identified with a mortality rate of 1.7%. A fall of greater than 15 feet (high-level fall) was associated with a higher mortality rate than low-level falls (2.4% compared with 1.0%, respectively). Ninety-eight patients had sustained a calvarial fracture and 93 experienced a basal skull fracture. Twenty-six patients had suffered a cerebral contusion, 25 a sub-arachnoid hemorrhage, 22 a subdural hematoma, and 12 had an epidural hematoma. Forty-nine patients required surgery for traumatic injuries; of these, 10 underwent craniotomy for evacuation of a blood clot. Height was not predictive of the Glasgow Coma Scale (GCS) score. In all four deaths resulting from a low-level fall there was an admission GCS score of 3, and abnormal findings were demonstrated on computerized tomography scanning. Death from high-level falls was attributable to either intracranial injuries (50%) or severe extracranial injuries (50%).

Intracranial injury is the major source of fall-related death in children and, unlike extracranial insults, brain injuries are sustained with equal frequency from low- and high-level falls in this population. The only cause of mortality from low-level falls was intracranial injury. Trauma triage criteria must account for these differences in the pediatric population.

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Sean D. Lavine, Lena S. Masri, Michael L. Levy and Steven L. Giannotta

✓ The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of potential brain-protection anesthetics, a group of patients treated with the intravenous agents propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane.

Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP anesthesia, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the group that did not receive brain protection (NBP). In the NBP group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients (four of four) in the NBP group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group (p < 0.0001). Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at decreased risk.

It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving isoflurane when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and its use in patients with multiple aneurysms need further evaluation before specific recommendations can be made.

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Sean D. Lavine, Lena S. Masri, Michael L. Levy and Steven L. Giannotta

The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of brain-protection anesthetics, a group of patients treated with the intravenous agents, propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane.

Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the isoflurane (ISO) group. In the ISO group, the mean duration of temporary occlusion was 3.9 ± 2.2 minutes for patients without infarction versus 12.2 ± 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 ± 10.6 minutes for patients without infarction and 18.5 ± 9.9 minutes for patients with infarction in the IVBP group. All patients in the ISO group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group. Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at a decreased risk.

It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving ISO when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and patients with multiple aneurysms need further evaluation before specific recommendations can be made.