Life expectancy and causes of death in a group of head-injured veterans of World War I.

The life spans and causes of death were examined for a group of Bavarian veterans of World War I who had suffered head injuries and for comparable control subjects who had not. The occurrence of posttraumatic fits was a significant prognostic factor for a higher death rate after the age of 50 years. Other indicators of the severity of injury did not lead to differences in the death rates. There were significantly more deaths due to cerebrovascular causes in the head-injured group than in the control group, but no subgroup was found to have significantly more cerebrovascular deaths than any other.

Analysis of brain abscess after penetrating craniocerebral injuries in Vietnam.

A population of 1221 patients from the Vietnam War with penetrating craniocerebral trauma was analyzed. Thirty-seven cases of brain abscess were documented (incidence 3%). This sequela occurred more frequently in association with extensive, deep penetrating injuries; deep, prolonged coma; cerebrospinal fluid fistulas; wound infections; facio-orbital cranial/air sinus injuries; and retained bone fragments. The mortality rate was 54%, and, of the patients who survived, 82% had significant morbidity. This is the last large population study of brain abscess after penetrating craniocerebral trauma before the availability of computed tomographic scanning and more comprehensive coma care. It should serve as base line data against which we can measure improvement.

Cerebrospinal fluid fistulas complicating missile wounds of the brain.

The records of 101 casualties of the war in Vietnam have been analyzed, with particular attention to missile wounds of the brain complicated by a cerebrospinal fluid (CSF) fistula. Fifty-four developed CSF drainage at the wound site, 30 presented with rhinorrhea, and 23 with otorrhea. Fifty of the 101 men developed infection, an incidence of 49.5%. The occurrence of a fistula in vertex wounds can usually be traced to failure to close the dura, or to achieve watertight closure of the dura primarily, or by graft. Approximately two-thirds of compound basilar fractures, complicated by rhinorrhea or otorrhea, are due to direct fractures of the anterior, middle, or posterior fossa. The remaining one-third are due to elusive "discrete" fractures of the base of the skull, occurring at a distance from the entry wound, and not in continuity with the fracture of the vault. While direct basilar fractures can readily be recognized, facilitating repair of the dura overlying the basilar fractures, "discontinuous" fractures pose a challenging diagnostic problem. More commonly occurring in vertex wounds crossing the midline, discontinuous fractures producing rhinorrhea or otorrhea may be identified with the aid of tomograms of the base of the skull. Their early diagnosis may well prove to be a significant factor in the reduction of morbidity and mortality of missile wounds of the brain complicated by a CSF fistula.

Evolution of craniotomy as a debridement technique for penetrating craniocerebral injuries.

A craniotomy debridement technique was recommended for penetrating craniocerebral injuries as early as 1940, in World War II. However, with due consideration for the bacterial contamination of penetrating injuries, the safety of this technique was questionable. The technique has been recommended in each succeeding war, but no data substantiating the safety or eventual sequelae have been available. Analysis of the data from the large Head Injury Registry of Vietnam casualties indicates that, in properly selected cases, debridement by craniotomy technique can be safe and efficacious.

Language and motor disorders after penetrating head injury in Viet Nam.

Aphasia occurred in 244 of 1030 patients with head wounds, correlating with gunshot cause (p < 0.03) and initial loss of consciousness (p < 10(-6)). Aphasia disappeared within 10 years in 84 cases (34%). Sensorimotor aphasia usually changed to motor aphasia; motor aphasia disappeared; and sensory aphasia persisted. These improvements continued years after the accompanying hemiparesis stabilized, and were not related to wound site, depth, or whether the wound was caused by gunshot or fragment. Parietal wounds caused hemiparesis more often (p < 10(-6))than did wounds elsewhere. Regardless of the features of the hemiparesis initially, the severity of the final syndrome was greatest in the hand and arm and least in the face.

A survey of public attitudes toward epilepsy in 1979 with an indication of trends over the past thirty years.

At 5 years intervals, during the past 30 years, the American Institute of Public Opinion has obtained answers to questions about epilepsy from representative members of the adult population throughout the United States. During this period, knowledge of epilepsy was found in 90 to 95% of the people interviewed. When those familiar with epilepsy were asked if they would object to their children playing with epileptics, the upward trend in those without objections from 1949 to 1979 was 57%, 68%, 67%, 77%, 81%, 84%, 89%. When asked if they thought epilepsy was a form of insanity, the trend in those who did not was: 59%, 68%, 74%, 79%, 81%, 86%, 92%. When asked if epileptics should be employed, the affirmative answers increased with the following variations: 45%, 60%, 75%, 82%, 76%, 81%, 79%. The adverse responses were proportionately reduced. In each of the seven surveys, the most favorable opinion was among the better educated, better employed, younger, and urban members of the population. The states in the eastern, midwestern, and western regions initially showed less prejudice than those in the southern region. Now there is greater uniformity in opinion throughout the nation. Factors that have contributed to the more enlightened opinion include educational efforts by professional and lay societies regarding epilepsy; improved control of seizures; employment by a number of major industries of individuals with a history of attacks; and more reasonable legal regulations concerning immigration, marriage, and the operation of motor vehicles.

Discrete regional analysis of norepinephrine, dopamine, choline acetyltransferase and glutamic acid decarboxylase in the brain of the newborn and pubescent monkey.

A method is described for the removal of discrete areas of the monkey brain. A detailed mapping of norepinephrine, dopamine, choline acetyltransferase and glutamic acid decarboxylase in the newborn and pubescent monkey brain is presented.

Local cerebral glucose utilization in newborn and pubescent monkeys during focal motor seizures.

The [14C]deoxyglucose method was used to determine the rate of local cerebral glucose utilization (LCGU) in newborn and pubescent monkeys during focal motor seizures induced by injecting penicillin into the face-hand area of the right motor cortex. Seizures were studied in 3 newborn and 6 pubescent monkeys, and 3 newborn and 4 pubescent monkeys were used as controls. In controls, the pattern of glucose utilization within structures of the sensorimotor system was quite differenet at the two age levels; newborns showed far less activity, especially in the neocortex and striatum. In the monkeys with seizures, the unilateral increase in LCGU relative to the controls was greater in newborn than in pubescent monkeys except in the cerebral and cerebellar cortices. The increased glucose utilization in cortical and subcortical structures of the newborns was ipsilateral to the discharging lesin and lacked the well-defined pattern seen in the pubescent monkeys. In general, newborn brain was capable of supporting a focal motor seizure but lacked the precise clinical and electrographic expressions or efficient energy metabolism that accompany maturation of the brain at puberty.

Propagation of focal motor seizures in the pubescent monkey.

The rate of local cerebral glucose utilization was determined for quantification of energy metabolism in macrostructures of the sensorimotor system during propagation of focal motor seizures in 24-month-old monkeys. The rate was measured in 4 control animals and in 4 monkeys each with seizures limited to the contralateral face, seizures of the contralateral face and upper extremity, and bilateral expression of seizures. Glucose utilization increased significantly, primarily unilaterally, with propagation. The increase was greatest in the sensory and motor cerebral cortices, putamen, and globus pallidus, was somewhat less in sensory and motor thalamic relay nuclei, and was least in the cerebellar cortex.

Effects of manipulation of the sensorimotor system on focal motor seizures in the monkey.

During focal motor seizures induced by injecting penicillin into the face-hand area of the right motor cortex of 24-month-old monkeys, the sensorimotor system was manipulated by three methods. Elimination, by a paralytic agent, of proprioceptive input from contracting muscles and joints did not alter the electrographic expression of the seizure or the pattern of local glucose utilization in cortical or subcortical components of the sensorimotor system. An overall increase in the rate of energy metabolism occurred in the paralyzed monkeys with electrographic seizures. Cryogenic destruction of up to 90% of the ipsilateral ventral caudal globus pallidus had no effect on electrographic or clinical expression of the seizure. Electrical stimulation of the ipsilateral ventral caudal globus pallidus caused reproducible maximum expression of electrographic and clinical seizure phenomena for the 90-second duration of the stimulus.

Cranioplasty: a review of 1030 cases of penetrating head injury.

A total of 491 cranioplasties performed in a population of 1030 cases of penetrating head injury are reviewed. The morbidity rate was 5.5%, and the mortality rate was 0.2%. The clinical criteria of improving cosmetic defects and restoring craniocerebral protection are established, based on the location and size of the skull defect. Cranioplasty after penetrating head injury should be deferred for a minimum of 1 year to control morbidity. Complication of the original injury and surgical debridement increase the morbidity rate of cranioplasty. Post-traumatic epilepsy is not related to skull defects per se; neither is it affected by cranioplasty. Acrylic is an acceptable cranioplasty material if there is strict adherence to good surgical technique.