An audit of carotid endarterectomy for internal carotid artery disease at Dunedin Hospital.

Carotid endarterectomy, mostly for symptomatic internal carotid artery stenosis, has been successfully performed in both the vascular and neurological surgery units at Dunedin Hospital. This study was performed to compare our results with those of the North American Symptomatic Carotid Endarterectomy Trial and the European Carotid Surgery Trial. The 30-day perioperative morbidity and mortality rate was 4.3% (1.2% < 95% Cl > 7.4%) which compares favourably with an estimated upper limit of 5.5% based on recent trial reports. The present study highlights the difficulty in modelling local clinical practice on results of major trials when standards of patient evaluation and surgical skill may differ from those of the large studies. To justify generalization of indications for intervention based on the multicentre trials, there must be continual monitoring of local surgical results, and standardized use of diagnostic investigations.

First impressions count: a controlled investigation of social skill following closed head injury.

This study examined social skills in 14 closed head injured (CHI) patients who were assessed at four months post-injury and compared with 19 orthopaedic control (OC) patients. Social skills deficits were found to be more common in the CHI patients, of whom over half were classified as socially unskilled. CHI patients displayed poorer social skills in the earlier (but not later) part of an extended social interaction, indicating that they make a poor first impression. It is suggested that poor initial impression formation skills may be one reason why CHI patients fail to establish and maintain friendships. Implications of these findings for patient management are discussed. Close others of CHI patients reported higher levels of mood disturbance. Higher levels of close other hostility were associated with social skills deficits in CHI patients.

Neuropsychological impairment and return to work following severe closed head injury: implications for clinical management.

AIMS: To study the rate and timing of return to work following severe closed head injury, and to compare the neuropsychological functioning of patients who successfully return to work with that of patients who fail to return to work. METHODS: The vocational status, level of cognitive functioning and personality functioning of a consecutive series of 66 patients who survived severe closed head injury was assessed between six months and three years postinjury. The level of cognitive and personality functioning of patients who returned to work were compared with that of patients who failed to return to work. RESULTS: Twenty five percent of patients failed to return to work, and a further 17% returned to work under special conditions of employment. Failure to return to work was related to the degree of neuropsychological impairment (cognitive deficit and adverse personality change), injury severity (duration of posttraumatic amnesia), and age. Multiple regression analysis found the total number of neuropsychological symptoms to be the strongest predictor of the patients' return to work. CONCLUSIONS: These findings suggest that neuropsychological symptoms are the main mechanism through which severe brain injury affects the ability to return to work. It is recommended that vocational rehabilitation of severe closed head injury patients be based on a comprehensive neuropsychological assessment.

Post-traumatic amnesia and Glasgow Coma Scale related to outcome in survivors in a consecutive series of patients with severe closed-head injury.

A consecutive series of 93 severe closed-head injury (SCHI) patients, discharged from hospital in a conscious state, were rated on the Glasgow Outcome Scale at 6 and 12 months post-injury. Patients were included in this study if they had a period of post-traumatic amnesia (PTA) exceeding 24 h. Approximately 80% of patients had made a good recovery by 12 months post-injury; a better outcome than has been found in studies using the presence of coma during the first 6 h post-admission to hospital to define severe head injury. When analysed individually, duration of PTA and Glasgow Coma Scale scores on admission to hospital were both strongly correlated with outcome. Only duration of PTA, however, contributed significantly to outcome variance when potential outcome predictors were assessed using a stepwise multiple regression analysis. The definition of severe head injury, the higher than usual incidence of good recovery in the present study, and the relationship between injury severity and outcome are discussed.

Long-term cognitive deficits in patients after surgery on aneurysms of the anterior communicating artery.

The long term recovery of a series of 27 patients who had undergone rupture and repair of an aneurysm of the anterior communicating artery was assessed using a number of neuropsychological measures. Testing took place 12 to 84 months post surgery. On the basis of the results from tests of intellect, memory, and conceptual learning, three subgroups of patients were identified: those with persuasive cognitive defects, those with evidence of residual frontal lobe damage and those who showed no evidence of dysfunction. The occurrence of cerebral vasospasm was the most consistent predictor of long term cognitive deficit.

Facial pain and muscle atrophy secondary to an intracranial tumour.

Orofacial pain rarely arises from a distant site. It is unusual for orofacial pain to be associated with wasting of the facial musculature and diminished sensation. This case report describes a patient who presented with temporomandibular joint pain dysfunction syndrome which was initially successfully managed with splint therapy. She re-presented later with unilateral wasting of the muscles of mastication, facial pain and diminished sensation ipsilaterally. An intracranial meningioma was diagnosed following an extensive series of investigations.

The relationship between social skill and family problem-solving following very severe closed head injury.

This study examined the relationship between level of social skill and family problem-solving behaviour in a group of 18, community dwelling, very severe closed head injury (CHI) patients who had suffered their injury at least 18 months previously, and who were still in contact with rehabilitation services. The main findings of this study were a positive relationship between CHI patients' level of social skill and their rate of positive effect, and an inverse relationship between the CHI patients' level of social skill and the rate of facilitative behaviour displayed by relatives during problem-solving interactions. It is suggested that socially unskilled CHI patients may be more demanding to interact with, and that this may cause a significant burden for their relatives.

Social interaction and speed of information processing following very severe head-injury.

Eighteen adults who had suffered a very severe closed head-injury more than 18 months previously and required long-term rehabilitative support were compared with a closely matched control group. Unlike previous studies, which have reported negative personality change involving an increase in aversive behaviour, our behavioural observation data suggest that a global reduction in behavioural productivity, or negative symptomatology, characterizes social interaction by this group. This resulted in their being judged less socially skilled, less likeable and less interesting, and thus less reinforcing to interact with. Speed of information processing was specifically impaired for the closed head-injury group, although this did not correlate with global behavioural ratings of social interaction behaviour. It is suggested that low behavioural productivity may be associated with family burden, and that the low quantity of social interaction experienced by severely head-injured adults may reflect the unreinforcing nature of their interactions.

Vertebral artery occlusion associated with closed head injury: report of three cases.

Vertebral artery occlusion associated with closed head injury is an uncommon clinical entity. Three cases are presented with discussion of the mechanisms of injury, pathology, diagnosis, possible treatment modalities and autopsy findings in the two fatalities. Angiography is essential for diagnosis and in fatal cases post-mortem examination of the entire length of the vertebral arteries should be routine.

The posterior operation in treatment of cervical spondylosis with myelopathy: a long-term follow-up study.

An analytical study of 59 patients who underwent the posterior operation for cervical spondylosis with myelopathy at the London Hospital between 1945 and 1960 has been made. The postoperative period of observation ranged from five to 20 years with an average of 10 years. Initially 36 patients were improved by the operation, 24 considerably so, and in 15 patients further deterioration was prevented. Five years after operation 33 patients were still improved and in five patients co-existent disease had become apparent. Ten years after operation 30 patients had maintained their initial improvement; progression of the disease accounted for a drop of 10% in the success rate initially achieved. No patient in this series developed postoperative instability of the cervical spine. Patients with less than two years' duration of symptoms and with less neurological disability fared better. The importance of a long follow-up period for the proper assessment of results is thus emphasized. It is suggested that the posterior operation has stood the test of time and will continue to maintain a useful place in the treatment of this condition. Some points are outlined for the successful practice of this operation.