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The oval pupil: clinical significance and relationship to intracranial hypertension

Lawrence F. Marshall, David Barba, Belinda M. Toole, and Sharon A. Bowers

✓ The oval pupil, or what has also been termed the “oblong” or “football” pupil, has been observed in 15 neurosurgical patients over a 2-year period. In 14 of the 15 patients, the intracranial pressure (ICP) was elevated, ranging from 18 to 38 mm Hg. While the oval pupil was primarily seen in patients suffering closed head injuries (11 cases), it was also observed in two patients with elevated ICP following hemorrhage from an arteriovenous malformation. In nine of the 14 patients in whom the pupillary abnormality was associated with intracranial hypertension, the oval pupil disappeared when the ICP was reduced to below 20 mm Hg. In four cases, the ICP could not be controlled and the pupil became progressively larger, and finally fixed and unreactive.

The oval pupil represents a transitional stage indicating transtentorial herniation with third nerve compression. Although it may be seen in the absence of intracranial hypertension (one case in this series), this appears to be relatively uncommon. The presence of such a pupil on examination in a patient suffering an intracranial catastrophe, be it head injury, subarachnoid hemorrhage, or intracerebral hemorrhage, suggests impending transtentorial herniation with brain-stem compression.

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The National Traumatic Coma Data Bank

Part 2: Patients who talk and deteriorate: Implications for treatment

Lawrence F. Marshall, Belinda M. Toole, and Sharon A. Bowers

✓ The records of the first 325 patients entered into the pilot phase of the National Traumatic Coma Data Bank were reviewed. Thirty-four severely head-injured patients who talked prior to deteriorating to a Glasgow Coma Scale (GCS) score of 8 or less were identified. Of those 34 patients, 18 died or were left vegetative and 16 recovered. While there were certain common factors between those who talked and died and those who talked and recovered, there were also significant differences. The common factors between the two groups were the length of time to deterioration or operative intervention (16 versus 18 hours, respectively), and the initial GCS scores (12.6 versus 12.4, respectively).

The primary differences between the groups included the mean age, the degree of midline shift seen on computerized tomography (CT), and the presence of subdural hematoma. Those who talked at some point postinjury, but who subsequently died, had a mean age of 50 years. Those who talked, deteriorated, and then recovered were found to have a mean age of 32 years. Seven of the 18 patients who talked and died had a shift of greater than 15 mm on CT, while this degree of shift was demonstrated in only one of 16 patients who talked, deteriorated, and recovered.

Subdural hematomas were significantly more common in the “talk and die” group, as was the overall need for operation. Since the overwhelming majority of patients with marked shift on CT have surgical lesions, early operative intervention is strongly recommended in these patients, prior to their inevitable deterioration.

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Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Niels Juul, Gabrielle F. Morris, Sharon B. Marshall, the Executive Committee of the International Selfotel Trial, and Lawrence F. Marshall

Object. Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.

Methods. The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-d-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.

Conclusions. Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

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Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Niels Juul, Gabrielle F. Morris, Sharon B. Marshall, the Executive Committee of the International Selfotel Trial, and Lawrence F. Marshall

Object

Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.

Methods

The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-D-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.5% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP >/= 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.

Conclusions

Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

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Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury

Niels Juul, Gabrielle F. Morris, Sharon B. Marshall, The Executive Committee of the International Selfotel Trial, and Lawrence F. Marshall

Object

Recently, a renewed emphasis has been placed on managing severe head injury by elevating cerebral perfusion pressure (CPP), which is defined as the mean arterial pressure minus the intracranial pressure (ICP). Some authors have suggested that CPP is more important in influencing outcome than is intracranial hypertension, a hypothesis that this study was designed to investigate.

Methods

The authors examined the relative contribution of these two parameters to outcome in a series of 427 patients prospectively studied in an international, multicenter, randomized, double-blind trial of the N-methyl-D-aspartate antagonist Selfotel. Mortality rates rose from 9.6% in 292 patients who had no clinically defined episodes of neurological deterioration to 56.4% in 117 patients who suffered one or more of these episodes; 18 patients were lost to follow up. Correspondingly, favorable outcome, defined as good or moderate on the Glasgow Outcome Scale at 6 months, fell from 67.8% in patients without neurological deterioration to 29.1% in those with neurological deterioration. In patients who had clinical evidence of neurological deterioration, the relative influence of ICP and CPP on outcome was assessed. The most powerful predictor of neurological worsening was the presence of intracranial hypertension (ICP ≥ 20 mm Hg) either initially or during neurological deterioration. There was no correlation with the CPP as long as the CPP was greater than 60 mm Hg.

Conclusions

Treatment protocols for the management of severe head injury should emphasize the immediate reduction of raised ICP to less than 20 mm Hg if possible. A CPP greater than 60 mm Hg appears to have little influence on the outcome of patients with severe head injury.

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Failure of the competitive N-methyl-d-aspartate antagonist Selfotel (CGS 19755) in the treatment of severe head injury: results of two Phase III clinical trials

Gabrielle F. Morris, Ross Bullock, Sharon Bowers Marshall, Anthony Marmarou, Andrew Maas, The Selfotel Investigators, and Lawrence F. Marshall

Object. Excessive activity of excitatory amino acids released after head trauma has been demonstrated to contribute to progressive injury in animal models and human studies. Several pharmacological agents that act as antagonists to the glutamate receptor have shown promise in limiting this progression. The efficacy of the N-methyl-d-aspartate receptor antagonist Selfotel (CGS 19755) was evaluated in two parallel studies of severely head injured patients, defined as patients with postresuscitation Glasgow Coma Scale scores of 4 to 8.

Methods. A total of 693 patients were prospectively enrolled in two multicenter double-blind studies. Comparison between the treatment groups showed no significant difference with regard to demographic data, previous incidence of hypotension, and severity of injury. As the study progressed, the Safety and Monitoring Committee became concerned about possible increased deaths and serious brain-related adverse events in the treatment arm of the two head injury trials, as well as deaths in the two stroke trials being monitored concurrently. The Selfotel trials were stopped prematurely because of this concern and because an interim efficacy analysis indicated that the likelihood of demonstrating success with the agent if the studies had been completed was almost nil.

Conclusions. Subsequently, more complete data analysis revealed no statistically significant difference in mortality rates in all cases between the two treatment groups in the head injury trials. In this report the authors examine the studies in detail and discuss the potential application of the data to future trial designs.

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Cause of decline in head-injury mortality rate in San Diego County, California

Melville R. Klauber, Lawrence F. Marshall, Belinda M. Toole, Sharen L. Knowlton, and Sharon A. Bowers

✓ Even with an increasing population, there were 100 fewer deaths due to head injury in San Diego County, California, in 1982 compared to 1980. During the 5 years from 1976 to 1980 there was nearly a constant death rate from head injuries, followed in the next 2 years by a decline of 24%. The number of deaths at the scene of injury declined 28%, and the number of individuals listed as dead on arrival at the hospital declined 68%. Mortality rates in the emergency room increased slightly and later death rates declined slightly. Mortality rates of hospitalized patients, adjusted for severity of injury, did not vary materially by year. This decline in deaths due to head injury followed a marked improvement in the county's emergency ground and prehospital air evacuation services. The data strongly suggest that advanced prehospital emergency medical services can substantially reduce mortality rates in head-injured patients. The authors postulate that some patients who ordinarily “would die now talk” because of early airway and circulatory management by highly trained paramedical personnel and airborne trauma specialists. Despite a search for other factors that might explain these observations, no satisfactory alternatives could be identified.

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Absent or compressed basal cisterns on first CT scan: ominous predictors of outcome in severe head injury

Steven M. Toutant, Melville R. Klauber, Lawrence F. Marshall, Belinda M. Toole, Sharon A. Bowers, John M. Seelig, and James B. Varnell

✓ The relationship of outcome to the appearance of the basal cisterns as seen on initial computerized tomography (CT) scanning was assessed in 218 consecutive severely head-injured patients entered into the second phase of the National Pilot Traumatic Coma Data Bank. Outcome could be directly related to the status of the basal cisterns on the initial CT scan. The mortality rates were 77%, 39%, and 22% among those with absent, compressed, and normal basal cisterns, respectively. This association between cisterns and outcome was shown to be strong after adjusting for Glasgow Coma Scale (GCS) score (p < 0.001).

The state of the cisterns was more important for those with higher GCS scores (scores 6 to 8) than for those with lower scores (scores 3 to 5). Patients with GCS scores of 6 to 8, with cisterns absent or not visualized, suffered nearly a fourfold additional risk of poor outcome, compared to those with normal cisterns. This indicates that the status of the cisterns can be used as an early noninvasive method of identifying patients at high risk of death or severe disability, in whom the initial neurological examination would potentially suggest otherwise.

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A new classification of head injury based on computerized tomography

Lawrence F. Marshall, Sharon Bowers Marshall, Melville R. Klauber, Marjan van Berkum Clark, Howard M. Eisenberg, John A. Jane, Thomas G. Luerssen, Anthony Marmarou, and Mary A. Foulkes

✓ A new classification of head injury based primarily on information gleaned from the initial computerized tomography (CT) scan is described. It utilizes the status of the mesencephalic cisterns, the degree of midline shift in millimeters, and the presence or absence of one or more surgical masses. The term “diffuse head injury” is divided into four subgroups, defined as follows: Diffuse Injury I includes all diffuse head injuries where there is no visible pathology; Diffuse Injury II includes all diffuse injuries in which the cisterns are present, the midline shift is less than 5 mm, and/or there is no high- or mixed-density lesion of more than 25 cc; Diffuse Injury III includes diffuse injuries with swelling where the cisterns are compressed or absent and the midline shift is 0 to 5 mm with no high- or mixed-density lesion of more than 25 cc; and Diffuse Injury IV includes diffuse injuries with a midline shift of more than 5 mm and with no high- or mixed-density lesion of more than 25 cc. There is a direct relationship between these four diagnostic categories and the mortality rate. Patients suffering diffuse injury with no visible pathology (Diffuse Injury I) have the lowest mortality rate (10%), while the mortality rate in patients suffering diffuse injury with a midline shift (Diffuse Injury IV) is greater than 50%. When used in conjunction with the traditional division of intracranial hemorrhages (extradural, subdural, or intracerebral), this categorization allows a much better assessment of the risk of intracranial hypertension and of a fatal or nonfatal outcome. This more accurate categorization of diffuse head injury, based primarily on the result of the initial CT scan, permits specific subsets of patients to be targeted for specific types of therapy. Patients who would appear to be at low risk based on a clinical examination, but who are known from the CT scan diagnosis to be at high risk, can now be identified.

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The National Traumatic Coma Data Bank

Part 1: Design, purpose, goals, and results

Lawrence F. Marshall, Donald P. Becker, Sharon A. Bowers, Carol Cayard, Howard Eisenberg, Cynthia R. Gross, Robert G. Grossman, John A. Jane, Selma C. Kunitz, Rebecca Rimel, Kamran Tabaddor, and Joseph Warren

✓ This paper describes the pilot phase of the National Traumatic Coma Data Bank, a cooperative effort of six clinical head-injury centers in the United States. Data were collected on 581 hospitalized patients with severe non-penetrating traumatic head injury. Severe head injury was defined on the basis of a Glasgow Coma Scale (GCS) score of 8 or less following nonsurgical resuscitation or deterioration to a GCS score of 8 or less within 48 hours after head injury.

A common data collection protocol, definitions, and data collection instruments were developed and put into use by all centers commencing in June, 1979. Extensive information was collected on pre-hospital, emergency room, intensive care, and recovery phases of patient care. Data were obtained on all patients from the time of injury until the end of the pilot study.

The pilot phase of the Data Bank provides data germane to questions of interest to neurosurgeons and to the lay public. Questions are as diverse as: what is the prognosis of severe brain injury; what is the impact of emergency care; and what is the role of rehabilitation in the recovery of the severely head-injured patient?