Thermal gelation of mixed egg yolk/kappa-carrageenan dispersions.

This study aims to evaluate the effect of gum content and pH on the thermal gelation of mixed egg yolk/κ-carrageenan (EY/κC) dispersions, monitored by linear viscoelastic measurements. Heat processing induces dramatic changes in the microstructure and viscoelastic properties of EY/κC systems, which may be attributed to a multistage mechanism that yields an interparticle gel network. An increase in κC content generally induces an enhancement in viscoelasticity. A reduction in pH hinders this enhancement and causes an anticipation of the multistage process, which confirms the importance of the electrostatic interactions of EY/κC dispersions. The viscoelastic properties of EY/κC gels generally fit a master mechanical spectrum, which suggests that the protein matrix generally dominates the microstructure of EY/κC gels. However, SEM images reveal formation of a κC network at low pH, at which some κC autohydrolysis may also play a role. Electrostatic attractions seem to favour interactions among EY aggregates and κC into the carrageenan network.

[Cranial lesions due to forceps delivery]. / Lesiones craneales secundarias a parto asistido con forceps.

Deliveries with forceps or vacuum-extraction increase the incidence of perinatal craneoencephalic lesions, for which reason cesarean sections are performed more frequently. We report 3 cases of cranial lesions due to forceps deliveries, 2 with depressed skull fractures and 1 with a depressed fracture and an associated epidural hematoma. Diagnosis is made on clinical and radiological founds with CT scan or MRI. Treatment is surgical and consists of elevation of the depressed fracture and evacuation of the hematoma. The correct use of forceps is very important to avoid this kind of lesions in the newborn, especially in cases of difficult delivery.

Lesiones craneales secundarias a parto asistido con forceps / Cranial lesions due to forceps delivery

Los partos asistidos con forceps o vacuum aumentanla incidencia de lesiones craneoencefálicas fetales,siendo la tendencia actual a realizar cesáreas en partosque se prevén difíciles.Presentamos una serie de tres casos de lesionescraneales secundarias a parto asistido con forceps, doscasos de fracturas deprimidas y una fractura deprimidacon hematoma epidural subyacente. El diagnóstico serealiza con la clínica y técnicas de imagen como TACo IRM. El tratamiento es quirúrgico en la mayoría decasos, con elevación de la fractura y evacuación delhematoma.La forma correcta de aplicar los forceps resultaesencial para prevenir lesiones craneales fetales, especialmenteen partos difíciles (AU)

Deliveries with forceps or vacuum-extractionincrease the incidence of perinatal craneoencephaliclesions, for which reason cesarean sections are performedmore frequently. We report 3 cases of craniallesions due to forceps deliveries, 2 with depressedskull fractures and 1 with a depressed fracture and anassociated epidural hematoma. Diagnosis is made onclinical and radiological founds with CT scan or MRI.Treatment is surgical and consists of elevation of thedepressed fracture and evacuation of the hematoma.The correct use of forceps is very important to avoidthis kind of lesions in the newborn, especially in cases ofdifficult delivery (AU)

[Childhood spinal tumours]. / Tumores espinales infantiles

We report a large series of 48 childhood spine tumors diagnosed and treated at our Hospital between 1986 and 2006. Spinal tumors in children are a rare and heterogeneous condition that frequently are diagnosed late because of their uncharacteristic clinical picture. Symptoms are usually limited to diffuse back pain or spinal deformities, prior to leg paresis or sphincter dysfunction. Diagnosis is usually made with MRI or CT. Treatment is surgical in most cases. The prognosis is variable due to the diverse histological findings and it may require the use of complementary treatments as chemotherapy or radiation.

Tumores espinales infantiles / Childhood spinal tumours

Presentamos una extensa serie de 48 tumoresespinales en niños diagnosticados y tratados en nuestrocentro en el período 1986-2006. Los tumoresespinales infantiles suponen una patología infrecuente yheterogénea que es habitualmente diagnosticada tardepor la inespecificidad del cuadro clínico. Los síntomassuelen limitarse a dolor difuso de espalda o deformidadesespinales meses antes de debutar con parálisisde miembros inferiores o trastornos esfinterianos. Eldiagnóstico se realiza con TAC o RM. En la mayoríade casos el tratamiento es quirúrgico. El pronóstico deestos tumores es variable dependiendo de la histologíade cada lesión, pudiendo requerir tratamiento complementariocon radioterapia y/o quimioterapia (AU)

We report a large series of 48 childhood spinetumors diagnosed and treated at our Hospital between1986 and 2006. Spinal tumors in children are a rare andheterogeneous condition that frequently are diagnosedlate because of their uncharacteristic clinical picture.Symptoms are usually limited to difuse backpain orspinal deformities, prior to leg paresis or sphinter dysfunction.Diagnosis is usually made with MRI or CT.Treatment is surgical in most cases. The prognosis isvariable due to the diverse histological findings and itmay require the use of complementary treatments aschemoterapy or radiation (AU)

[Brain-stem tumors in children]. / Tumores de tronco cerebral en la población pediátrica.

We report a large series of brain-stem tumors seen during 18 years of at our hospital. We diagnosed and treated a total of 42 patients between 1988 and 2006; 36 of them were operated with partial resection in most cases. Brain-stem tumors constitute a rare condition with very bad prognosis. A surgical complete resection of the mass is not possible in most cases, so the principal surgical objective is reduction and decompression. The best prognosis is seen in patients with low grade tumors with minimal neurologic deficit. Most of these tumors cause death in a short period, usually one year or less.

Tumores de tronco cerebral en la población pediátrica / Brain-stem tumors in children

Presentamos una serie de tumores de tronco cerebraldiagnosticados y tratados en nuestro centro duranteun período de 18 años. Se han revisado un total de 42pacientes entre los años 1982 y 2006; 36 de ellos fueronintervenidos, realizándose una resección parcial en lamayoría de los casos.Los tumores de tronco cerebral suponen una raraentidad patológica con muy mal pronóstico. En lamayoría de los casos no resulta posible una reseccióncompleta de la lesión, por lo que el principal objetivode la cirugía es la reducción de masa tumoral y ladescompresión. El mejor pronóstico se obtiene en lostumores de bajo grado de malignidad con mínimo déficitneurológico. La mayoría de estos tumores provocanla muerte en un breve período, habitualmente un año omenos desde el diagnóstico (AU)

We report a large series of brain-stem tumors seenduring 18 years of at our hospital. We diagnosed andtreated a total of 42 patients between 1988 and 2006;36 of them were operated with partial resection in mostcases.Brain-stem tumors constitute a rare condition withvery bad prognosis. A surgical complete resection of themass is not possible in most cases, so the principal surgicalobjetive is reduction and descompression. The bestprognosis is seen in patients with low grade tumors withminimal neurologic deficit. Most of these tumors causedeath in a short period, usually one year or less. (AU)

[Prevalence and consumption of medication in diabetes mellitus in Madrid (1996-2002)]. / Prevalencia y consumo de medicación antidiabética en la Comunidad de Madrid (1996-2002).

OBJECTIVES/AIMS: To determine the prevalence of diabetes mellitus treated with drugs and the prescription of drugs in diabetes (oral anti-diabetics and insulin) in the Community of Madrid between 1996-2002. METHODS: We used the indirect method for estimating the rate of prevalence of diabetes based on antidiabetic drug in the Madrid Community. We studied the consumption or oral antidiabetics (OH) and insulin (IN) in all the Madrid Community Area from 1996 to 2002. To make consumption uniform we used the daily doses/1,000 inhabitants/day (DHD). The total consumption was obtained using the official billing data and the annual population data provided by the "Institute Madrileño de Salud". RESULTS: The prevalence of diabetes mellitus increased 62.5% in the period studied, ranging from 1.6% in 1996 up to 2.6% in 2002. The DHD of oral drugs increased 87.8% from 12.2 in 1996 to 23.07 in 2002. The DHD of insulin decreased 28.2% from 3.99 in 1996 down to 3.11 in 2002. The OH/IN ratio increased 138%, from 3.11 to 7.42 in 2002. There is a tendency to increase biguanide and sulfonilureas with low risk of hypoglycemia. The total cost of insulin and oral medication increase every year, the increase of diabetic patients and the cost/DDD of the new drugs are factors that increase the total cost of diabetes. CONCLUSIONS: The prevalence of diabetes mellitus treated with drugs increased in the Community of Madrid. There is a progressive use of oral drugs versus insulin, and a tendency to prescribe biguanide, sulfonylureas, especially gliclazide and glimepiride. A tendency to substitute insulin with insulin analogues is also seen in the use of insulin. The cost of diabetes increases yearly.

Prevalencia y consumo de medicación antidiabética en la Comunidad de Madrid (1996-2002) / Prevalence and consumption of medication in diabetes mellitus in Madrid (1996-2002)

Objetivo. Determinar la evolución de la prevalencia de diabéticos tratados con fármacos, así como de la prescripción de antidiabéticos (antidiabéticos orales [ADO] e insulina) en la Comunidad de Madrid durante los años 1996-2002. Métodos. Para conocer la prevalencia de diabetes en la Comunidad de Madrid y ver su evolución hemos utilizado el método indirecto del consumo de fármacos (antidiabéticos). Estudiamos el consumo de ADO e insulina en todas las áreas de la Comunidad de Madrid desde 1996 hasta 2002. Con el fin de poder comparar con otros estudios elegimos la unidad estandarizada de medida de dosis diaria definida (DDD), así como la DDD/1.000 habitantes/ día (DHD). El consumo de fármacos fue facilitado por el Instituto Madrileño de Salud y los datos de población se obtuvieron de la tarjeta sanitaria individual (TSI) de cada área de la Comunidad. Resultados. La prevalencia de diabetes se incrementó en el período estudiado un 62,5%, del 1,6% en 1996 al 2,6% en 2002. La prescripción de ADO aumentó un 87,8%, del 12,2 DHD en 1996 a 23,07 en 2002. El consumo de insulina disminuyó un 28,2%, del 3,99 DHD en 1996 a 3,11 en 2002. El índice ADO/insulina se elevó un 138%, del 3,11 al 7,42 en 2002. Existe una modificación de prescripción tanto de ADO, mayor prescripción de biguanidas, así como de sulfonilureas de menor riesgo de hipoglucemia, como de insulinas, con una menor prescripción de insulina de acción intermedia y rápida por análogos de insulina. El coste total tanto de ADO como de insulina se incrementa anualmente por aumento de la población y la elevación de los coste/DDD de los nuevos fármacos. Conclusiones. La Comunidad de Madrid tiene una prevalencia baja de diabetes, existe una tendencia a la prescripción de ADO, destacando el uso de biguanidas y sulfonilureas, especialmente gliclazida y glimepiride. En el uso de insulina se evidencia una tendencia a sustituir las insulinas por análogos de insulina. El coste de la diabetes se incrementa anualmente

Objectives/aims. To determine the prevalence of diabetes mellitus treated with drugs and the prescription of drugs in diabetes (oral anti-diabetics and insulin) in the Community of Madrid between 1996-2002. Methods. We used the indirect method for estimating the rate of prevalence of diabetes based on antidiabetic drug in the Madrid Community. We studied the consumption or oral antidiabetics (OH) and insulin (IN) in all the Madrid Community Area from 1996 to 2002. To make consumption uniform we used the daily doses/1,000 inhabitants/ day (DHD). The total consumption was obtained using the official billing data and the annual population data provided by the «Institute Madrileño de Salud». Results. The prevalence of diabetes mellitus increased 62.5% in the period studied, ranging from 1.6% in 1996 up to 2.6% in 2002. The DHD of oral drugs increased 87.8% from 12.2 in 1996 to 23.07 in 2002. The DHD of insulin decreased 28.2% from 3.99 in 1996 down to 3.11 in 2002. The OH/IN ratio increased 138%, from 3.11 to 7.42 in 2002. There is a tendency to increase biguanide and sulfonilureas with low risk of hypoglycemia. The total cost of insulin and oral medication increase every year, the increase of diabetic patients and the cost/DDD of the new drugs are factors that increase the total cost of diabetes. Conclusions. The prevalence of diabetes mellitus treated with drugs increased in the Community of Madrid. There is a progressive use of oral drugs versus insulin, and a tendency to prescribe biguanide, sulfonylureas, especially gliclazide and glimepiride. A tendency to substitute insulin with insulin analogues is also seen in the use of insulin. The cost of diabetes increases yearly

Pediatric giant cell glioblastoma: a case report and review of the literature.

INTRODUCTION: Giant cell glioblastoma is a subtype of glioblastoma multiforme (GM) whose most characteristic histology is the presence of plentiful multinucleated giant cells. These tumours are very rare and account for only 5% of GM. They do not have specific localization, although normally they are supratentorial and affect mostly the temporal lobe. They may occur at any age, but mostly they occur in younger people than GM. They are infrequent in childhood, but they have longer survival in paediatric age. CASE REPORT: We present an 11-year-old girl that was operated but whose tumour recurred in a month after apparent total removal. DISCUSSION: We review in the literature the clinical, histological, immuno-histochemical and genetic characteristics, as well the prognosis of this tumour.

Prescripción de antidiabéticos orales y uso racional de glibenclamida: Posibilidades de mejora / No disponible

Objetivo: Conocer la prescripción de antidiabéticos orales y el uso de la prescricipción especifica de las especialidades farmacologicas de glibenclamida con el fin de mejor nuestra eficiencia. Diseño: Descriptivo, transversal durante años 2001-2002. Emplazamiento: Comunidad de Madrid, área 4. Mediciones: Determinamos las dosis diarias definidas (DDD) y las dosis definidas por 1000 habitantes(DHD)de los antidiabeticos orales a nivel de área durante el periodo 20012002, así como de cada prescripción especifica de las especialidades farmaceuticas de glibenclamida. Calculamos el indice de buena prescripción en los equipos de glibenclamida (Norglicem/Euglucon+Daonil); así como el ahorro potencial de glibenclamida si se realizara con la especialidad de menor coste. Resultados: La prescripción de antidiabeticos orales 2001 versus 2002 aumentó de 22,19 a 24,69 DHD. La glibenclamida continua siendo el antidiabético oral más prescrito con 7,49 DHD, con una tendencia a disminuir su prescripción. La metformina es el segundo antidiabetico más prescrito con un incremento en su prescripción del 44.84. Existe una tendencia a la prescrición de antidiabéticos de reciente comercialización. La prescripción específica de las especialidades farmacéuticas de glibenclamida son las de mayor coste, existiendo una tendencia a la valoración el coste en los equipos. El ahorro potencial de glibenclamida en los equipos de atención primaria, de pres-cribir la especialidad de menor coste sería de 39.395 euros. Conclusión: El aumento de la población mayor, la prescripción de especialidades farmacéuticas de mayor coste y la aparición de nueva medicación, son factores que influyen en el coste del tratamiento oral de la diabetes (AU)

Aims. The objective of the study is determine the use of oral antidiabetic and the prescription of specific glibenclamide in primary health. Design. Across over, observational study during 2001-2002. Localization. Primary health area 4 of Madrid. Measurement. We determinate the DDD, DHD and cost of oral drugs in diabetic patients type 2. The prescription was taken from the data-base of the area We valorized the ratio of good prescription for glibenclamida (Norglicem/Daonil+Euglucon-5), and the possible reduction of the cost on oral antidiabetc drugs in glibenclamide by the equips of primary health care Results. The prescription of oral drugs increase during the period 2001 versus 2002 increase from 22.19 to 24.69 DHD. Glibenclamida was the oral drug more use in 2002 with 7.49 DHD, with a decrease of 0.75% versus 2001. Metformin is the second drug use and increase versus 2001 in 44.84%.There is high increase in the prescription of new drugs. The use of specific glibenclamida were those of more cost. The potential decrease of cost in glibenclamide by primary health is about 39.395 euros. A better prescription by the ratio (Norglicem/Daonil+Euglucom) is possible, only 3 of the 28 group study have level high of 1. Conclusion. The increase of the poblation , the high cost of the prescription drugs and the increase of new drugs are factor that influence in the cost of oral treatment in diabetic patients type 2 (AU)

Evolución del consumo de antidiabéticos orales e insulinas enl a Comunidad de Madrid y el Área 4 de Madrid

Estudio descriptivo con la finalidad de valorar tanto la prescripción actual como conocer en que medida existen cambios en la utilización de los fármacos hipoglucemiantes. Material y métodos: Base de datos sobre el consumo tanto de número de envases como el importe de antidiabéticos orales e insulinas de la Comunidad de Madrid y del Área 4 de Madrid, así como el estudio de las DHD de dicho Área. Los datos fueron obtenidos de la Subdirección General de Atención Primaria, siendo procesados por el Servicio de Farmacia del Área 4 de Madrid. Resultados: el importe de antidiabéticos orales de la Comunidad de Madrid en el 2001 fue de 8.816.017,44 euros (1.466.861.878 ptaas.) y de insulinas 14.868325,9 euros ( 2.473.881.276 Ptas.). El consumo tanto los antidiabéticos orales como de insulina aumentaron en el período analizado 2000-2001. El incremento en el importe de antidiabéticos orales fue en la Comunidad de Madrid de 60.540.513 pesetas, los inhibidores de alfaglucosidasa en 4.718.340 pesetas, las biguanidas 44.687.749 pesetas, los insulino-secretagogos 72.428.145 pesetas y las glitazonas han supuesto en su primer año de comercializaión 12.615.408 pesetas. El incremento de los antidiabéticos orales tanto a nivel de Comunidad como del Área 4 ha sido debida al aumento deglicazida, glimepiride, repaglidina, miglitol y metformina, habiendo una disminución de acarbosa y sulfonilureas de primera generación. Respecto al incremento en el importe de insulinas destaca sobre todo la precripción y por tanto el importe de la insulina lispro. Conclusiones: las biguanidas hoy día es un fármaco de uso extendido. Existe una tendencia a la prescripción de nuevos fármacos que desplazan los ya existenten, así como un uso de especializadas más caras. Es necesaria la creación de Unidades de diabetes, mejorando la gestión clínica y calidad global de los pacientes diabéticos. (AU)

Linear Viscoelasticity of the Direct Hexagonal Liquid Crystalline Phase for a Heptane/Nonionic Surfactant/Water System

A linear viscoelastic characterization by small amplitude oscillatory shear and creep compliance tests was carried out for heptane/polyoxyethylene glycol nonylphenyl ether (EOa = 10)/water systems exhibiting a direct hexagonal liquid-crystalline structure. The influence of composition and temperature on the dynamic functions was considered. By adding heptane to the binary system, an increase in the critical Ninham-Israelachvili ratio defining the appearance of the hexagonal mesophase is likely to occur. Heptane solubilization at 25degreesC gave rise to the appearance of a "plateau" region in the frequency dependence of the dynamic functions, which was wider as heptane concentration increased and as temperature decreased. The Generalized Maxwell model fits the frequency dependence of the dynamic functions fairly well. The BSW-CW does not describe, in most cases, the relaxation spectrum of the hexagonal phase, except for binary systems at 20-25degreesC. The steady-state limiting viscosity of the hexagonal phase shows an Arrhenius-like dependence on temperature.

[Subdural hematoma associated with arachnoid cyst]. / Hematoma subdural asociado a quiste aracnoideo.

We describe 3 young patients with history of mild cranial trauma who presented the rare association of subdural hematoma and arachnoid cyst. Clinical and radiological signs are reviewed.

Meningioangiomatosis: advanced imaging and pathological study of two cases.

Meningioangiomatosis (MA) is a rare benign intracranial tumour of uncertain pathogenesis, with only 33 cases reported in the literature. Imaging features have been described in 21 cases, only 3 with contrast-enhanced MRI. We present two cases of MA with MRI and/or CT findings and gross, ultrastructural, and immunohistochemical characteristics. MRI is particularly helpful for establishing the origin of the lesion and its anatomical location, while CT shows calcification, if present. The pathological characteristics establish the diagnosis and underline the differences from other entities such as malignant meningioma, one of the most important differential diagnostic considerations.

Extradural hematoma: analysis of factors influencing the courses of 161 patients.

The clinical and computed tomographic (CT) findings in a series of 161 consecutive patients operated upon for postraumatic extradural hematoma are analyzed. Thirteen (8%) patients had delayed epidural hematoma formation. The overall mortality for the series was 12%, significantly lower than that observed during the prior "angiographic" period at the same unit (30%). Because all but 1 of the deaths occurred among the 66 patients unconscious at the time of operation (27% mortality in this subgroup), the authors sought differential factors between comatose and noncomatose patients at operation. There were no significant differences between these groups in age, sex, mechanism of injury, preoperative course of consciousness (lucid interval or not), or epidural hematoma location and shape. In contrast, significant differences were seen between the two subgroups in trauma-to-operation interval, hematoma volume, CT hematoma density (mixed low-high CT density vs. homogeneous hyperdensity), midline displacement, severity of associated intracranial lesions, and postoperative intracranial pressure (ICP). Patients comatose at operation usually evidenced a more rapid clinical deterioration (a shorter trauma-to-operation interval) and tended to have a large hematoma volume, a higher incidence of mixed CT density clot (hyperacute bleeding), more marked shift of midline structures, more severe associated lesions, and higher postoperative ICP levels.

Clinical, radiological, and pathological spectrum of angiographically occult intracranial vascular malformations. Analysis of 21 cases and review of the literature.

The clinical, radiological, and histopathological features of 21 cases of angiographically occult intracranial vascular malformations (AOIVM's) are analyzed, and a review of 241 additional appropriately documented, histologically verified cases collected from the literature is presented. In all, there were 115 (43.8%) arteriovenous malformations, 82 (31.2%) cavernous angiomas, 26 (9.9%) venous angiomas, 10 (3.8%) cases of capillary telangiectasis, and 29 (11%) mixed or unclassified angiomas. The result of the analysis shows that there are no essential differences in the patterns of clinical presentation, the computerized tomography (CT) appearance, or the surgical prognosis among these pathological types of vascular malformations. Certain histological features common to all AOIVM's (such as the small caliber, the more or less complete thrombosis of the malformed vessels, and the changes induced in the surrounding brain tissue by repeated microhemorrhages) seem to determine the biological behavior of the anomaly rather than the predominant type of vessel involved. Thus, subdivision of AOIVM's into the four classical pathological types has little practical value. Most AOIVM's are visualized by the CT scan and show a rather typical appearance. Surgical removal, which prevents rebleeding and ameliorates or suppresses seizure activity, is usually easy to perform and represents the treatment of choice for patients with clinically symptomatic AOIVM's.

Posttraumatic cerebral hemispheric swelling. Analysis of 55 cases studied with computerized tomography.

The authors have analyzed the clinical course and intracranial pressure (ICP) changes in 55 severely head-injured patients presenting with bulk enlargement of one cerebral hemisphere within a few hours after trauma. These patients represent 10.5% of a series of 520 patients with severe head injury studied with computerized tomography (CT). Cerebral hemispheric swelling has the highest mortality rate and the shortest survival period after trauma in all series of severe head injury. In this series, it was associated with an ipsilateral subdural hematoma of variable size in 47 patients (85%) or with a large epidural hematoma in five patients (9%); in three patients (5.4%) it occurred as an isolated lesion. Evacuation of an associated extracerebral hematoma, which was performed within 4 hours after injury in only 20% of cases, scarcely changed the patients' preoperative neurological status. The high incidence of arterial hypotension and/or hypoxemia at admission (47% of cases) and the severity of the clinical presentation (82% of patients scored 5 points or less on the Glasgow Coma Scale, 74% had unilateral or bilateral mydriasis, and 80% had an initial ICP above normal) correlated with a very poor final outcome (87% mortality). Only one of the 11 patients with normal initial ICP continued to have normal pressure throughout the course. High-dose thiopental failed to control severe intracranial hypertension in 24 patients (51%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 15 patients (31.4%) and definitive control in eight patients (17%), among whom were the seven survivors in this series. In the authors' experience, once ICP is controlled, barbiturate administration should not be discontinued until a control CT scan shows complete disappearance of the mass effect.

Acute epidural hematoma: an analysis of factors influencing the outcome of patients undergoing surgery in coma.

Mortality due to epidural hematoma is virtually restricted to patients who undergo surgery for that condition while in coma. The authors have analyzed the factors influencing the outcome of 64 patients who underwent epidural hematoma evacuation while in coma. These patients represented 41% of the 156 patients operated on for epidural hematoma at their centers after the introduction of computerized tomography (CT). Eighteen patients (28.1%) died, two (3.1%) became severely disabled, and 44 (68.8%) made a functional recovery. The mortality rate for the entire series was 12%, significantly lower than the 30% rate observed when only angiographic studies were available. A significant correlation was found between the final result and the mechanism of injury, the interval between trauma and surgery, the motor score at operation, the hematoma CT density (homogeneous vs. heterogeneous), and the hematoma volume. The patient's age, the course of consciousness before operation (whether there was a lucid interval), and the clot location did not correlate with the final outcome. The mortality rate was significantly higher in patients operated on within 6 hours or between 6 and 12 hours after injury than in those undergoing surgery 12 to 48 hours after injury. Compared with the patients operated on later, the patients undergoing surgery in the early period were, on the average, older and had more rapidly developing symptoms, more pupillary changes, lower motor scores at surgery, larger hematomas, a higher incidence of mixed CT density clots, more severe associated intracranial lesions, and higher postoperative intracranial pressure (ICP). The mechanism of trauma seems to influence the course of consciousness before and after surgery. Passengers injured in traffic accidents had a lower incidence of a lucid interval and longer postoperative coma than patients with low-speed trauma, suggesting more frequent association of diffuse white matter-shearing injury. The duration of postoperative coma correlated with the morbidity rate in survivors. Forty-eight patients (75%) had one or more associated intracranial lesions, and 70% of these required treatment for elevation of ICP after hematoma evacuation. An ICP of over 35 mm Hg strongly correlated with poor outcome; administration of high-dose barbiturates was the only effective means for lowering ICP in nine of 15 patients who developed severe intracranial hypertension after surgery. This study attempts to identify patients at greater risk for presenting postoperative complications and to define a strategy for control CT scanning and ICP monitoring.

Cerebral hemisphere swelling in severe head injury patients.

The clinical course and the intracranial pressure (ICP) changes in 66 severe head injury patients presenting bulk enlargement of one cerebral hemisphere within a few hours of trauma have been analyzed. These patients represent 11% of a series of 589 severe head injury cases studied with computerized tomography (CT). Cerebral hemisphere swelling, which was associated with an ipsilateral subdural haematoma of variable extent in 58 patients (88%), or a large epidural haematoma in 5 patients (7%), and occurred as an isolated lesion in 3 patients (4%), carried the highest incidence of uncontrollable intracranial hypertension, the highest mortality rate and the shortest survival period after trauma in the authors' severe head injury series. The high incidence of arterial hypotension and/or hypoxaemia at admission (48% of cases), and the severity of clinical presentation (82%) of patients scored 5 patients or less in the Glasgow Coma Scale, 77% had uni- or bilateral mydriasis and 82% initial ICP above normal limits) correlated with the very poor final outcome (85% mortality). Only one of the 12 patients with normal initial ICP continued to have low pressure throughout the course. High dose thiopental failed to control severe intracranial hypertension in 29 patients (44%) who had a fulminant, malignant course. A transient decrease in ICP elevation was achieved in 17 patients (26%) and a definitive control in 12 patients (18%), among them the 10 survivors in this series. In the authors experience once ICP is controlled, and unless haemodynamic instability compells action to the contrary, barbiturate should not be discontinued until a control CT scan shows complete disappearance of the mass effect.