Role of cerebral perfusion pressure monitoring in determining the outcome in patients with severe head injuries: Results in a series of 89 patients

Raised intracranial pressure is a well-known event following a severe head injury. This rise in turn affects the cerebral perfusion pressure [CPP] and the cerebral blood flow. Fall of CPP below the critical level induces the development of secondary cerebral insults in the form of cerebral ischaemia. Authors present a study, carried out over a period of 4 years, at the National Trauma Centre, in the Sultanate of Oma, involving a total of 89 patients with severe head injury [Glasgow coma scale [GCS] of 8 or less]. These patients were aggressively managed in the Neurosurgical Intensive Care Unit with volume expanders, cerebro-spinal fluid drainage, and systemic vasopressors, in an attempt to maintain a cerebral perfusion pressure above 70 mmHg. Of the 89 patients in the study, 56 had a favorable outcome [62.9%] and 33 patients had a poor outcome [37%]. Among the patients with a poor outcome 2 [2.2%] were persistent vegetative, 9 patients [10.1%] had severe disabilities, and a mortality of 24.7% [22 cases] was recorded. Among the patients with a favourable outcome, the mean initial ICP was 13.7 mmHg and the mean initial CPP was 72.1 mmHg. The mean ICP during their monitoring phase was 11.8 mmHg, while the mean CPP was 77.9 mmHg. In contrast, those patients with a poor outcome had an initial ICP of 26.1 mmHg and initial CPP of 55.2 mmHg. Also, these patients had a mean ICP of 26.5 mmHg and a mean CPP of 55.9 mmHg, inspite of aggressive management. Measures to maintain cerebral perfusion above 70 mmHg influence the outcome in severely head injured patients in our study. We believe that adequate level of CPP is an important parameter for achieving good outcome

Bilateral dilated unreactive pupils in paediatric patients following severe head injury - long-term outcome

Bilateral dilated fixed pupils in patients with severe traumatic brain injury are generally considered to represent a terminal event. They signify brainstem involvement or severe compression of the third cranial nerves. Since papillary functions are one of the criteria upon which further management decisions are based, bilateral unreactive pupils may lead to procrastination on the part of the surgeon. Authors present a retrospective analysis of a series of 30 paediatric patients aged up to 14 years with severe head injury [Glasgow coma score [GCS] 8 or less] and bilateral dilated unreactive pupils, who were admitted at the National Neurosurgical Centre, Oman between January 1996-December 2000. Patients with direct orbital trauma were excluded from the study. As per the protocol, the patients with severe head injury were aggressively managed at admission with elective ventilation and pharmacological paralysis. Our aim in this study was to analyse the outcome in this sub-group of patients with severe head injury with dilated fixed pupils despite adequate resuscitation and identify the prognostic factors that determine the ultimate outcome. Of the 30 patients, only 8 [26.6%] had a functional outcome and the remaining 22 [73.3%] a poor outcome, which included all six patients with polytrauma in shock at admission who later died despite resuscitation. Obliteration of basal cisterns [80% of cases] and focal brain contusion [46.6%] were the commonest computed tomography [CT] scan findings. Factors adversely affecting survival included shock, initial GCS of 3-4 and obliteration of the basal cisterns on CT scan. Most of the surviving patients on long-term follow-up revealed appreciable motor improvement but significant neurobehavioral and cognitive deficits

solitary primary aspergillus brain abscess in an immunocompetant host: CT guided stereotaxy with an excellent outcome

Cerebral aspergillosis is a rare clinical condition, which is often fatal despite aggressive medical and surgical intervention. Primary central nervous system [CNS] fungal infections, where the brain is the sole site of infection in the absence of extracranial focus, are exceedingly rare. Authors report a successfully managed case of a primary solitary aspergillus brain abscess in the occipital lobe of a healthy gentleman without any previous history of medical illness. Initially, computed tomography [CT], guided stereotactic aspiration of the occipital lobe abscess, and later trephine craniotomy for the excision of the abscess with concomitant aggressive medical therapy [amphotericin-B, flucytosine] were curative. Interesting clinical, CT and operative findings are presented and discussed

Spontaneous appearing and disappearing acute traumatic intracranial haematomas - an interesting clinical entity case reports and review of literature

Two cases of appearing and disappearing traumatic intracranial haematomas have been described. In the first case, with an initiol normal CT brain scan, a delayed intracerebral haematomas appeared ten hours after injury, while in the second case, an acute subdural haematoma, seen immediately after traumatic brain injury [TBI], disappeared ten hours later. The importance of a delayed CT brain scan in cases of TBIs has been emphasised