Management of blunt injury to the internal carotid artery.

The management of vascular injury to the internal carotid artery (ICA) is controversial. We undertook a retrospective review of 14 patients with blunt injuries to the ICA and found three types of ICA injury, often presenting with delayed symptomatology. Six patients had intraluminal arterial stenosis or obstruction and were treated with anticoagulants. Five patients had pseudoaneurysms. Three of these were treated with balloon occlusion of the ICA above and below the orifice of the aneurysm, one with aneurysmorrhaphy, and one with resection and interposition vein graft. Three patients sustained a carotid cavernous fistula and were treated by balloon occlusion of the fistula while patency of the ICA was maintained. Treatment rendered all patients either asymptomatic or with residual deficits only. Angiography is essential to anatomically delineate the injury. The vascular surgeon, the neurosurgeon, and the interventional radiologist all make important contributions to the successful treatment of patients with blunt ICA injuries.

Use of high frequency jet ventilation during mechanical hyperventilation to reduce intracranial pressure in patients with multiple organ system injury.

Eleven patients with multiple organ system injury, including significant closed head injury, all required positive end-expiratory pressure (PEEP) for treatment of their pulmonary pathological condition. Additionally, the need for intracranial pressure (ICP) monitoring had previously been established on clinical evaluation by the Neurosurgery Service. Seven of the 11 patients met the criteria for invasive hemodynamic monitoring. Hemodynamic monitoring data are supplied for these 7 patients. All patients, after the initial institution of conventional means of hyperventilation, were transitioned to high frequency jet ventilation (HFJV) to evaluate the effects of HFJV during mechanical hyperventilation. There was a statistically significant decrease in ICP (mean decrease of 7.2 mm Hg). There was also a statistically significant fall in PaO2 from 131 to 101 torr. This was not associated with an appreciable decrease in oxygen delivery. There was no change in cardiac output or intrapulmonary shunt fraction. It is concluded that successful control of ICP was possible in all cases without impairment of cardiac output, oxygen delivery, or cerebral perfusion pressure, even when the pulmonary abnormality required the use of PEEP.

Immediate mini-myelography in acute cervical cord injuries.

The use of contrast myelography in the evaluation of acute cervical spinal cord trauma is controversial. The purpose of employing such a technique is to demonstrate any persistent extradural cord compression after the spine is realigned by skeletal traction. The surgical correction of such compression may result in enhanced neurological recovery. The "mini-myelogram" is accomplished by performing a lateral C1/C2 spinal puncture and injecting a low volume of Pantopaque into the subarachnoid space. Demonstration of significant extradural compression results in emergency surgery for appropriate decompression. A small percentage of patients may enjoy enhanced recovery due to the decompression. A description of the technique and results of 90 patients undergoing mini-myelography are presented.

Intracranial pressure monitoring in patients with severe head injury.

Increased intracranial pressure (ICP) has an adverse effect on the clinical course of patients with severe head injuries. Direct intracranial measurement is the only method of knowing the precise ICP. At the Maryland Institute for Emergency Medical Services Systems, elevations in ICP are treated according to an aggressive protocol. Our experience with this protocol has led to the following conclusions: 1) ICPs above 25 mm Hg are associated with an unacceptable mortality, 2) aggressive medical treatment of patients with an ICP of 16 mm Hg can decrease the number of patients whose ICPs reach 25 mm Hg, and 3) the overall mortality of severe head injury can be reduced with such a protocol. ICP monitoring can be a valuable parameter in the management of severe head injury. With continuous accurate reading of ICP, sound theraputic decisions can be made about the patient's care that, ultimately, can effect the patient's survival and outcome.

Effect of intracranial pressure monitoring and aggressive treatment on mortality in severe head injury.

During 1977-1978, 127 patients with severe head injury were admitted and underwent intracranial pressure (ICP) monitoring. All patients had Glasgow Coma Scale (GCS) scores of 7 or less. All received identical initial treatment according to a standardized protocol. The patients' average age was 29 years; 60% had multiple trauma, and 35% needed emergency intracranial operations. Treatment for elevations of ICP was begun when ICP rose to 20 to 25 mm Hg, and included mannitol therapy and drainage of cerebrospinal fluid (CSF) when possible. Forty-three patients (34%) had ICP greater than or equal to 25 mm Hg; of these, 36 (84%) died. The mortality rate of the entire group was 46%. During 1979-1980, 106 patients with severe head injury were admitted and underwent ICP monitoring. Their average ager was 29 years; 51% had multiple trauma, and 31% underwent emergency intracranial surgery. All patients received the same standardized protocol as the previous series, with the exception of the treatment of ICP. In this present series: if ICP was 15 mm Hg or less (normal ICP), patients were continued on hyperventilation, steroids, and intensive care; if ICP was 16 to 24 mm Hg, mannitol was administered and CSF was drained; if ICP was 25 mm Hg or greater, the patients were randomized into a controlled barbiturate therapy study. Twenty-six patients (25%) had ICP's of 25 mm Hg or greater, compared to 34% in the previous series (p less than 0.05), and 18 of these 26 patients (69%) died. The overall mortality for this current series was 28% compared to 46% in the previous series (p less than 0.0005). This study reconfirms the high mortality rate if ICP is 25 mm Hg or greater; however, the data also document that early aggressive treatment based on ICP monitoring significantly lessens the incidence of ICP of 25 mm Hg or greater and reduces the overall mortality rate of severe head injury.

Steroids in severe head injury: A prospective randomized clinical trial.

This is a prospective randomized study of the efficacy of steroid therapy in patients with severe head injury. One hundred patients were randomized into two equal groups: the steroid group received 5 mg/kg/day of methylprednisolone, and the nonsteroid group received no drug. The groups were similar in their clinical features. All patients received a standardized therapeutic regimen. The patients were also classified as early responders or nonresponders to the overall treatment protocol without regard to steroid administration, on the basis of change in Glasgow Coma Scale score during the first 3 days of admission. There was no statistically significant difference in the outcome of the steroid and nonsteroid group at 6 months. Of the responders who were on steroids, 74% had good outcomes or were disabled, compared with 56% of the responders who did not receive steroids. In the nonresponder group, the patients on steroids were actually associated with a worse outcome than those who did not receive steroids: 75% of the nonresponders who received steroids were dead or vegetative, compared to 56% of those who were not receiving steroids. The data suggest that: 1) the effect of steroids may be different for different patient groups; 2) in order to identify these patients, a sensitive coma scale is needed; and 3) a rational approach to steroid therapy in head-injured patients may be to start all patients on steroids, but to discontinue their use in patients identified as not benefiting from steroid therapy.

The role of computed tomography in acute head injury.

Computed tomography (CT) of the head provides the ability to rapidly evaluate patients with acute head injuries. Moreover, CT aids in surgical planning, prognosticating outcome and recovery time, and monitoring nonsurgical injuries. The authors review the ways in which CT is employed in a multiple trauma center.