Early postoperative seizures and endovenous phenytoin. Preliminary clinical data.

Early seizures represent a major complication in the post operative course of patients operated on for supratentorial tumors or AVMs. The real effectiveness of the AEDs prophylaxis to reduce the occurrence of post operative seizures is controversial. We proposed a prophylactic treatment with endovenous PHT consisting of two infusions of PHT (mean dosage of 18 mg/kg; mean time of 1 hr) perioperatively and during the first postoperative day. The interruption of the previous oral anticonvulsant treatment is not required. The endovenous route should permit a rapid reach of the therapeutical range. Sixty-six patients were treated. Fifty-one patients received two infusions and 15 patients only one infusion. The serum concentration of PHT performed at 24 hrs of operation was in most of patients (more than 80%) in the lower part of the therapeutical range while at 24 hrs of the second infusion was in the higher part or over the range. The overall prevalence of seizures was 10.6%. In the first group the incidence was 7.8%, in the second one was 20%. All the seizures appeared within 48 hrs of the operation. All the patients in the first group had single seizures, 2 patients of the second one experienced two seizures. No status epilepticus was observed. Alteration of consciousness and mild hypotension were the most common side effects. They never required major measurements and were mild, transient and completely reversible. We are starting with a randomized study based on a larger sample of patients which will allow a more reliable statistical analysis.

Respiratory complications during artificial barbiturate coma.

Artificial barbiturate coma was induced in 13 patients with disorders of consciousness from traumatic or spontaneous diseases. Early respiratory complications consisting with Adult Respiratory Distress Syndrome (ARDS) were found in 10 out of these 13 patients; on the contrary, only 2 out of 13 patients, treated with routine intensive care therapy without barbiturate, showed analogous respiratory complications. The literature on the subject and the possible pathophysiological mechanism of respiratory distress are discussed.

Long-term results in 62 cases of post-traumatic complete apallic syndrome.

After the transition state of decerebrate coma, at least four different kinds of the so-called apallic status can be identified: 1. Complete apallic syndrome: coma vigil, alertness without any awareness, mass movements only, impairment of sleep rhythm, absence of any emotional responses, postural abnormalities, some primitive motor responses, tetraplegia, and alteration of muscle tone. 2. Incomplete apallic syndrome: some of the features of the complete apallic syndrome are lacking, and the patient shows emotional reactions with appropriate grimacing and some appropriate motor responses. 3. False apallic syndrome: most signs of complete apallic syndrome are present, but the patient is in touch with the environment. This condition is somewhat similar to the so-called locked-in syndrome. 4. Functional apallic syndrome: full clinical picture of the complete apallic syndrome but full recovery within a few days. Long-term results in 62 patients, aged between 4 and 62, affected by a post-traumatic complete apallic syndrome are reported. Thirty two patients were operated upon and 30 were not operated upon. Out of these cases, 38 died after weeks or months; 3 patients entered a chronic apallic status; 2 patients are improving; 10 recovered with severe neurological or psychic sequels or both; 4 recovered with minimal sequels, and 5 without sequels; no patients in these two last groups were aged more than 20.

Severe traumatic coma in infancy and childhood: results after surgery and resuscitation.

This study deals with 390 cases of severe traumatic coma in infancy, childhood and youth, aged between 4 months and 19 years. Cases in which unconsciousness lasted less than 24-48 hours have not been considered here. 161 patients were operated upon for intracranial space-occupying lesions or for open head injury: extradural haematomas 60; extradural haematomas + brain lacerations and/or subdural haematomas 16; acute subdural haematomas 18; brain laceration 36; open head injuries 17; decompressive operations, hydromas and contusions 14. 102 patients recovered and 59 died. 229 subjects were given only to resuscitation treatment. 164 recovered and 65 died. Recovery and mortality rate are discussed in relation to the pathologicial lesions and to the clinical picture (severity, evolution and duration of coma). Overall mortality rate was 31%. Mortality was higher in operated patients (36.6%) and lower in patients in whom space-occupying lesions were not demonstrated by angiography and who underwent only resuscitation treatment (28%). The lowest rate was observed in cases of extradural haematoma (25.4%) and open head injury (23%). Highest mortality rate have been observed in cases of decerebrated coma (with or without signs of low brain stem impairment). Complete recovery can be achieved even after prolonged decerebration. 31 patients showed the typical picture of the "apallic syndrome": in 28 cases after prolonged decerebrated coma, in 3 cases after coma without decerebration. Of our 31 cases, 4 died, 4 are still in a chronic apallic state and 23 recovered. Of these, 10 patients had a remarkable recovery and 13 remained severely disabled.

Hypokalaemia after pneumoencephalography.

The changes in plasma electrolytes and blood pH and gases following the insufflation of air into the subarachnoid space for pneumoencephalography were investigated. The only significant change observed was a rapid fall of plasma potassium most evident at 60 minutes. A concomitant reduction of the urinary Na/K ratio supports the possibility that the change observed may be due to the stimulation of aldosterone secretion caused by this procedure, though its rapid occurrence and reversibility indicate that other influences might at least in part be responsible.