Intracranial pressure. Effects of pneumoperitoneum in a large-animal model.

BACKGROUND: The effects of pneumoperitoneum on intracranial pressure (ICP) have received relatively little attention. This study was undertaken to investigate the changes in ICP occurring as a result of increased intraabdominal pressure (IAP) and positioning in animals with normal and elevated ICP. METHOD: Five pigs (average weight 60 lb) were studied. A subarachnoid screw was placed for ICP monitoring. End tidal CO2 was monitored. Ventilation was performed to keep PCO2 between 30 and 50 mmHg. Measurements of arterial blood gases, mean arterial blood pressure, and ICP were recorded at four different levels of intraabdominal pressure (IAP 0, 8, 16, and 24 mmHg), both in the supine and Trendelenburg positions. A Foley catheter was introduced into the subarachnoid space to elevate the intracranial pressure, and the same measurements were performed. RESULTS: There was a significant and linear increase in ICP with increased IAP and Trendelenburg position. The combination of increased IAP of 16 mmHg and Trendelenburg position increased ICP 150% over control levels. CONCLUSIONS: Patient positioning and level of IAP should be taken into consideration when performing laparoscopy on patients with head trauma, cerebral aneurysms, and other conditions associated with increased ICP.

Fatal cerebral gunshot wounds: factors influencing organ donation.

Patients with clinical brain death following head injury are important potential cadaveric organ donors. We analyzed our series of cranial gunshot wounds with particular attention to the frequency and patterns of organ donation after fatal injuries. Sixty-six patients with gunshot wounds to the head, including 59 with intracranial involvement (43 male, average age 26 years) were seen during a 4-year period. Injuries were limited to the head in 50 of 59 patients. Overall mortality was 66 per cent. Predictors of mortality included Glasgow Coma Scale (GCS) of six or less (93%), self-inflicted gunshot wounds (75%), and computed tomography (CT) findings of bihemispheric injury (87%) or ventricular injury (82%). Of the 39 patients who died, 28 met standard criteria for brain death, and nine of these went on to organ procurement. Thirteen families refused donation, and six patients were not harvested for reasons including old age, pregnancy, suspicion of AIDS, coroner refusal, and failure to pursue consent. Principles essential to maximal organ retrieval include: 1) Recognition that patients suffering cerebral gunshot wounds represent potential organ donors and that certain factors are predictive of mortality; 2) Critical care/trauma team approach with standardized management and timely declaration of brain death; 3) Early search for family members and prompt notification of organ procurement agencies; 4) Sensitivity to cultural issues influencing donation; and 5) Programs to increase public awareness of organ donation.

Coagulopathy and catecholamines in severe head injury.

The prospective study reported here evaluated the relationship between coagulopathy, catecholamines, and outcome in severe head trauma. Thirty-six trauma patients (10 with penetrating injuries, 26 with blunt injuries, 50% overall mortality) were evaluated. These patients had severe head trauma (Glasgow Coma Scale score less than 9). Blood was analyzed for platelet count, prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen, D-dimer, antithrombin III, protein C, and protein S levels. A 24-hour urine sample was collected for vanillylmandelic acid (VMA), normetanephrine, and metanephrine determinations. A control group of five patients undergoing elective neurosurgery was also studied. Statistically significant differences between head injury survivors and nonsurvivors were present for platelet count, PT, and fibrinogen activity. There were no differences in the results of the other coagulation tests or in urinary catecholamine levels. The trauma patients differed from the elective neurosurgery patients with regard to D-dimer levels, PT, PTT, protein C levels, and urinary normetanephrine concentrations. Head trauma patients have a coagulopathy that is absent in patients following elective neurosurgical procedures. The coagulopathy may correlate with poor survival in head trauma and may be related to a catecholamine surge.

Hypersexuality or altered sexual preference following brain injury.

Eight patients are described in whom either hypersexuality (four cases) or change in sexual preference (four cases) occurred following brain injury. In this series disinhibition of sexual activity and hypersexuality followed medial basal-frontal or diencephalic injury. This contrasted with the patients demonstrating altered sexual preference whose injuries involved limbic system structures. In some patients altered sexual behaviour may be the presenting or dominant feature of brain injury.

CT-guided stereotactic placement of ventricular cannula.

Cannulation of a small lateral ventricle for the injection of medication was achieved by using a CT-guided stereotactic technique. Methodology is discussed.

The role of intraoperative ultrasound in neurosurgery.

High resolution real time intraoperative ultrasound was used in a number of cases to identify, localize, and characterize intracranial abnormalities. Five case reports illustrate the advantage of this technique during neurosurgical operative procedures.

Hemangiopericytoma of the cervical spine: report of an unusual case.

A hemangiopericytoma of the cervical spine in a 31-year-old woman is possibly the first reported in the orthopedic literature. There is some confusion about the most efficacious treatment. Based on six cases in the medical literature, it would appear that adjunctive radiation, postoperatively, helps to decrease the recurrence rate of the tumor.

Subarachnoid hemorrhage secondary to ruptured aneurysms in infants. Report of two cases.

Two infants with subarachnoid bleeding from middle cerebral artery aneurysms are presented, with detailed case histories.

Cerebral malakoplakia.

A newborn male developed diffuse myoclonus. Right frontal craniotomy revealed a thin hemispheric mantle and a cyst communicating with the right lateral ventricle. In the biopsy of the cyst wall there were the characteristic findings of malakoplakia, granulomatous inflammation with von Hansemann histiocytes and Michaelis-Gutmann bodies. The child died at 1 1/2 years of age.