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Robert L. Grubb Jr.

Following a long illness, Henry G. Schwartz, former editor of the Journal of Neurosurgery, died on December 24, 1998 at the age of 89 years.

The author provides an annotated chronology of Dr. Schwartz's life and some highlights of his distinguished career.

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Robert L. Grubb Jr.

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Mark Camel and Robert L. Grubb Jr.

✓ The case records of 114 patients were reviewed to ascertain the efficacy of bedside twist-drill craniostomy and continuous closed-system catheter drainage for the treatment of chronic subdural hematomas. Ninety-eight (86%) patients achieved an excellent outcome, and seven (6%) had no significant improvement. The total mortality from all causes was 8% in this group. Successful catheter drainage of the chronic subdural hematoma was accomplished by either one or two catheter placements in 102 (90%) patients. Twelve patients required additional operative procedures. The mean duration of hospitalization for the study group was 16 ays. No infections occurred in these patients. Remission of the clinical syndrome did not require the adiographic resolution of the chronic subdural hematoma.

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Vafa Rahimi-Movaghar

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William J. Powers, Robert L. Grubb Jr. and Marcus E. Raichle

✓ The importance of hemodynamic factors in the pathogenesis and treatment of cerebrovascular disease remains uncertain. The extracranial-intracranial (EC-IC) bypass trial has been criticized for failing to identify and separately analyze those patients with chronic reduction in regional cerebral perfusion pressure (rCPP) who might be most likely to benefit from surgery. Positron emission tomography (PET) measurements of regional cerebral blood flow (rCBF) and blood volume (rCBV) were performed on 29 patients with symptomatic occlusion or intracranial stenosis of the carotid arterial system prior to undergoing EC-IC bypass surgery. Twenty-four patients had evidence of reduced rCPP (increased rCBV/rCBF ratio) distal to the arterial lesion. Of 21 patients who survived surgery without stroke, three suffered ipsilateral ischemic strokes during the 1st postoperative year. A nonrandomized control group of 23 nonsurgical patients with similar clinical, arterio-graphic, and PET characteristics experienced no ipsilateral ischemic strokes during the 1st year following PET. Based on these results in 44 patients, the probability that successful surgery reduces the occurrence of ipsilateral ischemic stroke 1 year later was calculated. This probability ranged from 0.045 for a 50% reduction to 0.168 for a 10% reduction. Thus, there was little evidence to suggest that measurements of cerebral hemodynamics can identify a group of patients who would benefit from EC-IC bypass surgery.

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Chad W. Washington and Robert L. Grubb Jr.

Object

More than 1.5 million Americans suffer a traumatic brain injury (TBI) each year. Seventy-five percent of these patients have a mild TBI, with Glasgow Coma Scale (GCS) Score 13–15. At the authors' institution, the usual practice has been to admit those patients with an associated intracranial hemorrhage (ICH) to an ICU and to obtain repeat head CT scans 12–24 hours after admission. The purpose of this study was to determine if there exists a subpopulation of mild TBI patients with an abnormal head CT scan that requires neither repeat brain imaging nor admission to an ICU. This group of patients was further classified based on initial clinical factors and imaging characteristics.

Methods

A retrospective review of all patients admitted to a Level I trauma center from January 2007 through December 2008 was performed using the hospital Trauma Registry Database, medical records, and imaging data. The inclusion criteria were as follows: 1) an admission GCS score ≥ 13; 2) an isolated head injury with no other injury requiring ICU admission; 3) an initial head CT scan positive for ICH; and 4) an initial management plan that was nonoperative.

Collected data included age, etiology, initial GCS score, time of injury, duration of ICU stay, duration of hospital stay, and anticoagulation status. Primary outcomes measured were the occurrence of neurological or medical decline and the need for neurosurgical intervention. Imaging data were analyzed and classified based on the predominant blood distribution found on admission imaging. Data were further categorized based on the Marshall CT classification, Rotterdam score, and volume of intraparenchymal hemorrhage (IPH). Progression was defined as an increase in the Marshall classification, an increase in the Rotterdam score, or a 30% increase in IPH volume.

Results

Three hundred twenty-one of 1101 reviewed cases met inclusion criteria for the study. Only 4 patients (1%) suffered a neurological decline and 4 (1%) required nonemergent neurosurgical intervention. There was a medical decline in 18 of the patients (6%) as a result of a combination of events such as respiratory distress, myocardial infarction, and sepsis. Both patient age and the transfusion of blood products were significant predictors of medical decline. Overall patient mortality was 1%.

Based on imaging data, the rate of injury progression was 6%. The only type of ICH found to have a significant rate of progression (53%) was a subfrontal/temporal intraparenchymal contusion. Other variables found to be significant predictors of progression on head CT scans were the use of anticoagulation, an age over 65 years, and a volume of ICH > 10 ml.

Conclusions

Most patients with mild TBI have a good outcome without the necessity of neurosurgical intervention. Mild TBI patients with a convexity SAH, small convexity contusion, small IPH (≤ 10 ml), and/or small subdural hematoma do not require admission to an ICU or repeat imaging in the absence of a neurological decline.

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Roy P. Baker and Robert L. Grubb Jr.

✓ A case of complete fracture-dislocation of the lower cervical spine in which there were no permanent neurological sequelae is presented. The absence of permanent neurological deficits with this type of injury is rare. The primary mechanism of injury in this patient was believed to be hyperextension with rupture of the ligamentous structures, allowing complete dislocation of the C-6 body while the posterior elements remained in good alignment due to multiple fractures which “decompressed” the spinal cord.

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Ayub K. Ommaya, Robert L. Grubb Jr. and Ronald A. Naumann

✓ The distribution of coup and contre-coup contusions and subdural hematomas after frontal and occipital impacts has been studied in the rhesus monkey. The effect of skull fracture on these lesions is noted, and the data compared to known postmortem observations in man. The translation/cavitation theory for brain injury as presently conceived is not supported by these data. The skull distortion and head rotation hypothesis offers opportunities for developing a better theory for brain injury by direct as well as indirect impact. The significance of these observations for design of protective devices is briefly discussed.