Gunshot wounds to the head: gang- and non-gang-related injuries and outcomes.

PRIMARY OBJECTIVE: This study examined the differences between gang and non-gang-related incidents of penetrative missile injuries in terms of demographics, motivation, intra-cranial pathology, transit time, injury time and clinical outcome. RESEARCH DESIGN: Retrospective and prospective chart review. METHODS AND PROCEDURES: Between 1985-1992, 349 patients with penetrating missile injuries to the brain presenting to LAC-USC were studied. EXPERIMENTAL INTERVENTIONS: Inclusion criteria were implemented to keep the cohort as homogenous as possible. Patients excluded were those with multiple gunshot wounds, non-penetrating gunshot wounds to the head, systemic injuries and cases in which the motivation for the incident was unknown. MAIN OUTCOMES AND RESULTS: Gang-related shooting slightly out-numbered non-gang-related incidents. Demographic analysis showed both a male and Hispanic predominance for both gang- and non-gang-related victims and significant differences in gender, race and age. Occipital entrance sites were more common in the gang-related vs temporal entrance sites in the non-gang-related. Mean transit time to the emergency department for gang-related shootings was less than non-gang-related shootings (24.4 vs 27.8 minutes). Most shooting incidents took place between 6pm and 3am. No difference between survival and outcome was noted between gang and non-gang victims. CONCLUSIONS: Significant differences were found between gang- and non-gang-related shooting victims in terms of demographics, entrance site and transit time. No difference was found between injury time, survival and outcome between gang and non-gang populations.

Gamma knife radiosurgery for metastatic melanoma: an analysis of survival, outcome, and complications.

OBJECTIVE: Although the mainstays for treatment of metastatic brain disease have been surgery and/or external beam radiation therapy, an increasing number of patients are being referred for stereotactic radiosurgery as the primary intervention for their intracranial pathological abnormalities. The lack of efficacy and cognitive and behavioral consequences of whole brain irradiation have prompted clinicians to select patients for alternative therapies. This study analyzes the effectiveness of Leksell gamma unit therapy for metastatic melanoma to the brain. METHODS: We present our experience with 59 Leksell gamma unit treatment sessions in 45 consecutive patients who presented with metastatic melanoma to the brain. Five of these procedures were performed as salvage therapy for patients who needed second radiosurgical treatment for new lesions that were remote from the previous targets and were not included in the overall analyses. RESULTS: The population included 78% male patients. The mean patient age was 53 years (age range, 24-80 yr). The mean time from diagnosis of primary melanoma to discovery of brain metastasis was 43 months (median, 27.5 mo; range, 1-180 mo). At the time of diagnosis of brain disease, 35.5% of the patients (16 of 45 patients) had neurological symptoms, 77.7% (35 of 45 patients) had known visceral metastases, and 11.1% (5 of 45 patients) had seizure disorders. Eighty-six percent of the lesions (80 of 93 lesions) were cortical, 12% (11 of 93 lesions) were cerebellar, 1% (1 of 93 lesions) were pontine, and 1% (1 of 93 lesions) were thalamic. Fifty-seven percent of the sessions (31 of 54 sessions) were performed for a single lesion, 24.1% (13 of 54 sessions) for two lesions, 9.2% (5 of 54 sessions) for three lesions, 7.4% (4 of 54 sessions) for four lesions, and 1.8% (1 of 54 sessions) for five lesions. The mean treatment volume was 5.6 cc, with a mean prescription of 21.6 Gy to the 56.0% mean isodose line. The median survival time of the patients in our population, using Kaplan-Meier curves, was 43 months from the time of diagnosis of primary melanoma (range, 3-180 mo) and 8 months (range, 1-20 mo) from the time of gamma knife treatment. Complications included seizures within 24 hours of the procedure in four patients, with transient nausea and vomiting in three patients, transient worsening of preprocedure paresis responsive to steroids in three patients, and increased confusion in one patient. All 45 patients were located for follow-up (mean follow-up duration, 1 yr). After gamma knife treatment, 78% of the patients (35 of 45 patients) experienced either improved or stable neurological symptomatology before death or at the time of the latest follow-up examination. There were 26 deaths (58%). The cause of death was determined to be neurological in only 2 of 45 patients (7.7%). Follow-up magnetic resonance images revealed a 97% local tumor control rate of gamma knife-treated lesions, with 28% radiographic disappearance (9 of 32 cases). Six patients developed new lesions remote from radiosurgical targets and underwent second procedures. CONCLUSION: Although metastatic melanoma to the brain continues to have a foreboding prognosis for long-term survival, gamma knife radiosurgery seems to be a relatively safe, noninvasive, palliative therapy, halting or reversing neurological progression in 77.8% of treated patients (35 of 45 patients). The survival rate matches or exceeds those previously reported for surgery and other forms of radiotherapy. Only 7.7% of the patients in our study population who died as a result of metastatic melanoma (2 of 26 patients) died as a result of neurological disease. The routine use of therapeutic level antiseizure medication is emphasized, considering the findings of our review.

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection.

The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of potential brain-protection anesthetics, a group of patients treated with the intravenous agents propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP anesthesia, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the group that did not receive brain protection (NBP). In the NBP group, the mean duration of temporary occlusion was 3.9 +/- 2.2 minutes for patients without infarction versus 12.2 +/- 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 +/- 10.6 minutes for patients without infarction and 18.5 +/- 9.9 minutes for patients with infarction in the IVBP group. All patients (four of four) in the NBP group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group (p < 0.0001). Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving isoflurane when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and its use in patients with multiple aneurysms need further evaluation before specific recommendations can be made.

Outcome for preterm infants with germinal matrix hemorrhage and progressive hydrocephalus.

OBJECTIVE: An analysis of 76 preterm infants with Grade III or IV intracranial hemorrhage and surgically treated progressive hydrocephalus was undertaken to determine mortality, intellectual impairment, and motor deficit. METHODS: The variables examined were degree of prematurity, birth weight, sex, Apgar scores, extent of intracranial hemorrhage, seizures, age at time of initial placement of a ventricular catheter reservoir to control hydrocephalus, need to convert the reservoir to a ventriculoperitoneal shunt, timing of the conversion of the reservoir to a ventriculoperitoneal shunt, and number of shunt revisions. Outcome was assessed for statistical significance using hierarchical linear regression and logistic regression analyses. RESULTS: Linear regression analysis determined that mortality was best predicted, in order of importance, by extent of intracranial hemorrhage, number of shunt revisions, and birth weight (P < 0.0001, R = 0.79). Grade of hemorrhage, weight at birth, and presence of seizure activity were the most important determinants of motor outcome (P < 0.001, R = -0.78). CONCLUSIONS: Logistic regression analysis of the 41 long-term survivors determined that grade of hemorrhage was the most important variable in determining cognitive outcome (P < 0.0001), motor function (P < 0.0001), and presence of seizure activity (P < 0.001). A logistic model of survival determined that grade of hemorrhage and multiple shunt revisions (more than five) were the most important determinants (P < 0.0001) of survival. In conclusion, the overwhelming factor in determining outcome in this patient group was the extent of intracranial hemorrhage.

Temporary occlusion of the middle cerebral artery in intracranial aneurysm surgery: time limitation and advantage of brain protection.

The risk of focal infarction secondary to the induced reversible arrest of local arterial flow during microsurgical dissection of middle cerebral artery (MCA) aneurysms was evaluated further to define the optimal approach to temporary arterial occlusion. To compare the effectiveness of brain-protection anesthetics, a group of patients treated with the intravenous agents, propofol, etomidate, and pentobarbital, administered individually or in combination, was compared to a group treated with the inhalational agent isoflurane. Forty-nine consecutive MCA aneurysm surgeries involving the temporary clipping of the parent vessel were retrospectively reviewed. Thirty-eight patients received intravenous brain-protection (IVBP) anesthesia. Groups of patients with and without infarctions, and receiving and not receiving IVBP, were compared based on the duration and nature of temporary arterial occlusion. Postoperative radiographic evidence of new infarction was used as the threshold for failure of occlusion tolerance. The overall infarction rate was 22.4% (11 of 49 patients), including 15.8% (six of 38 patients) in the IVBP group versus 45.5% (five of 11 patients) in the isoflurane (ISO) group. In the ISO group, the mean duration of temporary occlusion was 3.9 +/- 2.2 minutes for patients without infarction versus 12.2 +/- 4.3 minutes for patients with focal infarction (p < 0.01). In contrast, the mean duration was 13.6 +/- 10.6 minutes for patients without infarction and 18.5 +/- 9.9 minutes for patients with infarction in the IVBP group. All patients in the ISO group who underwent occlusion lasting 10 minutes or longer suffered an infarction versus five of 23 patients in the IVBP group. Patients with multiple aneurysms were found to be at increased risk of developing focal infarction, whereas those treated with intermittent temporary clip application were at a decreased risk. It is concluded that patients in whom focal iatrogenic ischemia is induced during MCA aneurysm clip ligation have a significant advantage compared with those receiving ISO when they are given pentobarbital as the primary neuroprotective agent or when they receive propofol or etomidate titrated to achieve electroencephalographic burst suppression, particularly if more than 10 minutes of occlusion time is required. It is also concluded that 10 minutes is a general guideline for safe, temporary occlusion of the MCA. The use of intermittent temporary arterial occlusion and patients with multiple aneurysms need further evaluation before specific recommendations can be made.

Treatment of recurrent malignant gliomas with chronic oral high-dose tamoxifen.

The present clinical trial was undertaken to assess the clinical safety and possible efficacy of administering tamoxifen to patients with recurrent malignant glial tumors at dosages calculated to achieve levels sufficient to inhibit protein kinase C within the tumor cells. Chronic p.o. tamoxifen was administered in very high dosages to 32 patients (20 males and 12 females; age range, 26-75 years; mean, 49 years) with histologically verified malignant glioma [anaplastic astrocytoma (12 patients) or glioblastoma multiforme (20 patients)] who had demonstrated clinical and radiographical progression or recurrence following external beam radiation therapy (and additional chemotherapy in 11; immunotherapy in 2). The dosage of tamoxifen administered was 200 mg/day to males and 160 mg/day to females given in a twice daily schedule. Clinical and radiographical (defined as a greater than 50% decrease in volume of the enhancing lesion volume on magnetic resonance imaging and a decrease in metabolic activity on serial positron emission tomographic scans) response was noted in 8 patients (25%; 4/12 with anaplastic astrocytoma and 4/20 glioblastoma multiforme), with an additional 6 patients (19%) exhibiting stabilization of disease with minimal side effects. Median survival from the time of diagnosis for the entire cohort was 24 months (104 weeks), for the anaplastic astrocytoma group 42.5 months (185 weeks), and for the glioblastoma group 17.4 months (75.5 weeks). From the initiation of tamoxifen, median survival for the entire cohort was 10.1 months (44 weeks), for the anaplastic astrocytoma group 16 months (69 weeks), and for the glioblastoma group 7.2 months (31 weeks). The mean length of follow-up of all patients after initiating tamoxifen was 16 months (69 weeks), while the mean length of follow-up of alive patients is 22.6 months (98 weeks) (range up to 51 months). These data suggest that a subgroup of patients with malignant gliomas respond or stabilize with chronic high-dose tamoxifen therapy. This therapy may represent an alternative or adjuvant to existing chemotherapies for these tumors; further clinical trials are warranted.

Gradient of pressure and time between proximal anal canal and high-pressure zone during internal anal sphincter relaxation. Its role in the fecal continence mechanism.

PURPOSE: The normal response to rectal distention is a relaxation of the proximal anal canal (PAC). We hypothesized that this mechanism would require a gradient of pressure and time to preserve continence. METHODS: Sixteen volunteers (10 male), mean age, 41.5 (range, 24-60) years, were studied using an eight port axial catheter with a compliant balloon at its tip. Relaxation was induced by a small volume of rectal distention (15-30 ml of air) and was recorded until recovery of resting anal pressure (RAP). Duration of relaxation was measured until recovery of RAP. Amplitude of relaxation was determined between RAP before rectal distention (RAP-BR) and pressure at the point of maximum relaxation (RAP-PMR). Gradient of pressure was determined by comparing RAP-PMR in the high-pressure zone (HPZ) and PAC. Contraction in the distal anal canal was interpreted as external anal sphincter contraction (EASC) and was compared with RAP-PMR in the HPZ. RESULTS: Relaxation was significantly greater in PAC than in HPZ (50 vs. 36 percent; P = 0.001). RAP-PMR was significantly higher in HPZ than in PAC (30.7 vs. 12.6 mmHg; P = 0.001). EASC was observed in six patients and did not show significant difference with RAP-PMR in HPZ (39.7 vs. 36.3 mmHg; not significant). Relaxation began at the same time in all levels but lasted significantly longer in PAC compared with HPZ (13.5 vs. 9.4 sec; P = 0.003). CONCLUSION: Anal relaxation induced by small volume rectal distention involves a gradient in the pressure and time of relaxation between PAC and the HPZ.

Patients with Glasgow Coma Scale scores 3, 4, 5 after gunshot wounds to the brain.

Even this information is only partial. To study fully the effects of treatment would require optimal care at all points from time of injury, including rapid prehospital resuscitation, rapid transport to an optimally equipped and staffed hospital, immediate evaluation and treatment of the initial injury and all complications, rapid and comprehensive rehabilitation, and supportive and flexible home and work settings for the patient on discharge. Patients would need to be stratified for premorbid characteristics, including intelligence, personal traits, and training. Prolonged follow-up, possibly for several years, would be required to determine true outcome. No current study contains sufficient numbers of patients treated optimally and studied for prolonged periods, but this should be done. One way of looking at such patients is to decide that many should be treated to salvage a few. The other way of looking at them is that so many must receive care, at great emotional and economic cost to themselves and others, that such treatment is inappropriate for any of them. Treating all such patients would be a major undertaking. If most of these patients were treated vigorously, a great proportion of them would still die but probably not for a number of days. During this period, their families would be under extreme stress. Once stabilized and receiving ongoing care, some patients would enter a permanent vegetative state and survive for prolonged periods until their prognosis was clear and care was withdrawn, again causing family stress as well as high cost. Some would likely survive although impaired. The charges and real costs of care for all these patients would be tremendous. The question therefore arises as to how to decide what to do about caring for a large group of patients whose maximal care would be costly in emotional and financial terms, particularly at a time when it is recognized that resources for medical care are going to be limited. When discussing such patients as a group with a view toward developing practice guidelines, many considerations must be brought to bear. One consideration is the certainty of the prognosis in both a quantitative and a qualitative sense in an individual case. It is not clear that one can be certain in patients except when there are overwhelmingly unfavorable features. As has been noted, even patients who have been shot through the geographic center of the brain and are posturing can make excellent recoveries. This would push toward aggressive treatment for many patients. Decision making must therefore be considered in terms of bioethics. The major principle-based systems of bioethics are deontologic, arising from accepted principles, and utilitarian, arising from effect on outcome. A virtue-based ethic for physicians arising from "the caring bond and the public trust" is being revived as a balance to analytical ethics. A similar orientation from the point of view of patients is communitarian ethics, that is asking for only what is reasonable and not so much as might harm others. Some of the issues to be considered include the sanctity of life while taking into account the criteria for life--vegetative function versus some level of mental function. One must also review each decision from the viewpoints of all the parties involved--patients, family and friends, physicians, and society--in the context of a heterogeneous society in which individual rights and tolerance enforced by law are primary features. In the patients' terms, there is a desire and right to medical care to maintain a healthy productive life. Even if impaired to some extent, patients may still have an interest in living. Balancing benefits and burdens of life is a complex problem. There is also the right, based on patients' values, to refuse care if there is the wish not to take a chance of having a significantly compromised existence. Such declaration before injury should be honored...

Fecal diversion for penetrating colon injuries--still the established treatment.

PURPOSE: An analysis of the existing literature on primary repair of colon injuries was undertaken to determine if there is sufficient evidence that this approach is superior to fecal diversion. METHODS: After a thorough literature search, three prospectively randomized studies comparing primary repair with fecal diversion in the management of colon injuries were identified. A variety of factors were examined, including the number of patients in each study arm, morbidity rates, as well as exclusion criteria. An analysis was performed to determine the number of patients required to establish statistical superiority of one procedure over the other. RESULTS: Pooling of the data contained in the aforementioned reports does not provide sufficient statistical power to support the superiority of primary repair of colon injuries. To demonstrate a 5 percent difference between the two approaches, a prospective, randomized study consisting of 200 patients in each arm is necessary. CONCLUSION: The present literature does not support a statistically valid advantage of primary repair over fecal diversion in the management of traumatic colon injuries.

Introducción al estudio del receptor al N-Metil-D-Aspartato / Introduction to the study of the N-Methyl-D-Aspartate receptor

Objetivos: Analizar toda la información publicada en los últimos diez años sobre el receptor al N-Metil-D-Aspartato (NMDA). Establecer una correlación farmaco-clínica con respecto a la modulación del dolor y determinar su importancia en anestesiología. Lugar: Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo. Base de datos: Base electrónica Medline de donde se seleccionaron todos los trabajos publicados en idioma inglés sobre el tema y búsqueda de información en castellano de lo publicado en los últimos 10 años. Estrategia de búsqueda: NMDA, dolor, modulación del dolor, protección cerebral. Discusión: Los receptores celulares son estructuras que permiten comandar el metabolismo íntimo de las células que los poseen. Estos interactúan en forma directa a través de un segundo mensajero citoplasmático. En el neuroeje de los mamíferos, se encuentran numerosas neuronas que contienen en su membrana el receptor al NMDA. El bloqueo de éste por drogas que actúan en forma competitiva o no competitiva, produciría analgesia, permitiría la modulación del estímulo doloroso y algunos trabajos demuestran su importancia como protectores cerebrales ante la isquemia. Conclusión: Los inhibidores de los receptores al NMDA como la dizocilpina, actualmente en fase experimental, o la ketamina, adquirirían un rol muy importante en nuestra especialidad en el manejo del dolor y la protección cerebral.(AU)

Introducción al estudio del receptor al N-Metil-D-Aspartato / Introduction to the study of the N-Methyl-D-Aspartate receptor

Objetivos: Analizar toda la información publicada en los últimos diez años sobre el receptor al N-Metil-D-Aspartato (NMDA). Establecer una correlación farmaco-clínica con respecto a la modulación del dolor y determinar su importancia en anestesiología. Lugar: Hospital de Gastroenterología Dr. Carlos Bonorino Udaondo. Base de datos: Base electrónica Medline de donde se seleccionaron todos los trabajos publicados en idioma inglés sobre el tema y búsqueda de información en castellano de lo publicado en los últimos 10 años. Estrategia de búsqueda: NMDA, dolor, modulación del dolor, protección cerebral. Discusión: Los receptores celulares son estructuras que permiten comandar el metabolismo íntimo de las células que los poseen. Estos interactúan en forma directa a través de un segundo mensajero citoplasmático. En el neuroeje de los mamíferos, se encuentran numerosas neuronas que contienen en su membrana el receptor al NMDA. El bloqueo de éste por drogas que actúan en forma competitiva o no competitiva, produciría analgesia, permitiría la modulación del estímulo doloroso y algunos trabajos demuestran su importancia como protectores cerebrales ante la isquemia. Conclusión: Los inhibidores de los receptores al NMDA como la dizocilpina, actualmente en fase experimental, o la ketamina, adquirirían un rol muy importante en nuestra especialidad en el manejo del dolor y la protección cerebral.

Outcome prediction after penetrating craniocerebral injury in a civilian population: aggressive surgical management in patients with admission Glasgow Coma Scale scores of 3, 4, or 5.

In an attempt to evaluate the response of patients who have low admission Glasgow Coma Scale scores (GCS) after a penetrating craniocerebral injury to aggressive management, we evaluated a series of 190 patients with penetrating injuries who presented with a GCS score of 3, 4, or 5 during a 6-year period. Entrance criteria required replicable neurological examinations that were not altered by the presence of hypotension, drugs/toxins, or systemic injury. The surgical patients included 21 patients with an admission GCS score of 3, 24 with an admission GCS score of 4, and 15 with an admission GCS score of 5. All patients underwent surgical intervention and aggressive perioperative management in the neurosurgical intensive care, including resuscitative protocols. Five of the patients with a GCS score of 3 survived, all with poor outcomes. Seven of the patients with a GCS score of 4 survived, although only one had a good outcome. Eleven of the patients with a GCS score of 5 survived. Five had a Glasgow Outcome Score of 2, five had a Glasgow Outcome Score of 3, and one had a Glasgow Outcome Score of 4. We have devised a prospective model of outcome based on our series in an attempt to predict nonsurvivors at admission (while overpredicting for survivors). The variables most predictive of mortality include admission GCS score and subarachnoid hemorrhage in one model and admission GCS score and pupillary changes in a second, when pupillary response was definitive at admission (P < or = 0.00005).(ABSTRACT TRUNCATED AT 250 WORDS)

Penetrating craniocerebral injury resultant from gunshot wounds: gang-related injury in children and adolescents.

We prospectively and retrospectively reviewed a series of 780 patients who presented to the University of Southern California/Los Angeles County Medical Center with a diagnosis of gunshot wound to the brain during an 8-year period. Of these, 105 were children ranging in age from 6 months to 17 years. Injuries were gang related in 76 (72%) children and adolescents. Stepwise linear regression analysis was used to formulate a predictive model of outcome in this population. Patient age (F = 10.92), sex (F = 9.32), occipital entry site (F = 8.17), bihemispheric injury (F = 8.50), and admission Glasgow Coma Scale (F = 69.91) were all found to correlate with outcome (P < 0.05). Significant differences between pediatric and adult populations were noted in transit time, entrance site, and age-related outcome. Occipital or assassination-type wounds were most common in children. In addition, a younger age was associated with poor outcome (P < 0.0001). We describe both the economic and racial trends in our population of patients in addition to weapon type and toxicological evaluation. The Department of Neurological Surgery is becoming directly involved in providing information to children at the junior high school level regarding gang activity and brain and spinal cord injury. In conjunction with the Community Youth Gang Services Organization and Think First Organization, we are attempting to integrate prevention through education and community mobilization. This is a plan aimed at informing and recovering the youth affected by gangs.

The significance of subarachnoid hemorrhage after penetrating craniocerebral injury: correlations with angiography and outcome in a civilian population.

Certain clinical factors are considered to have an effect on patient outcome after penetrating missile injury. These include bilateral hemispheric injury, ventricular hemorrhage, intracerebral hemorrhage, mass effect, and missile or bony fragmentation. The relationship of subarachnoid hemorrhage (SAH) after penetrating craniocerebral injury and outcome is unknown. In addition, controversy exists regarding the role of angiography and the incidence of traumatic intracranial aneurysm in this population. Finally, can we assume that the incidence of traumatic intracranial aneurysm is equal in military and civilian populations, given the absence of penetrating shrapnel injury in civilian populations? Now that computed tomography has supplanted angiography as the primary diagnostic modality, increasing vigilance on the part of the physician and examination of angiography in high-risk patients should allow for enhanced outcome. We evaluated 100 patients with a diagnosis of cerebral gunshot wound over a 12-month period. All patients were evaluated neurologically at the time of admission and had imaging studies. Thirty-one patients with radiological evidence of SAH on computed tomography underwent angiography. Angiograms were limited to the side of the injury in patients with single-lobe or unilateral multilobe injuries and were bilateral in patients with bilateral hemispheric involvement. One intracranial aneurysm (3.2%) was documented and treated surgically. In those patients who died within 48 hours of admission, 68% had SAH as compared with only 17% of those surviving. Outcome was based upon neurological evaluation at the time of discharge and at the time of clinical follow-up at 3 and 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)