Articles: brain-injuries.
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Comparative Study
Effect of small-volume resuscitation on intracranial pressure and related cerebral variables.
Head injury outcome is adversely affected by the presence of hypotension. Therapies directed at rapidly correcting hypotension may improve outcome. ⋯ Small-volume resuscitation with hypertonic saline and dextran and diaspirin cross-linked hemoglobin significantly improved mean arterial pressure and cerebral perfusion pressure compared with Ringer's lactate. These data suggest that small-volume resuscitation with hypertonic saline and dextran or diaspirin cross-linked hemoglobin may effectively limit or prevent secondary ischemic brain injury after head injury and shock.
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Resuscitation with hypertonic saline/dextran (HSD) has been suggested to be efficacious in patients who have traumatic brain injury and are hypotensive. We undertook a cohort analysis of individual patient data from previous prospective randomized double-blinded trials to evaluate improvements in survival at 24 hours and discharge after initial treatment with HSD in patients who had traumatic brain injury (head region Abbreviated Injury Score > or = 4) and hypotension (systolic blood pressure < or = 90 mm Hg). ⋯ Patients who have traumatic brain injuries in the presence of hypotension and receive HSD are about twice as likely to survive as those who receive standard of care.
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Preservation of a high cerebral perfusion (mean arterial) pressure to prevent ischemia has become the primary focus during treatment of severe head trauma because ischemia is favored as a triggering mechanism behind intracellular brain edema development and poor outcome. A high cerebral perfusion pressure, however, simultaneously may increase the hydrostatic vasogenic edema. The present paper evaluates the mechanisms behind the vasogenic edema by analyzing the physiologic hemodynamic mechanisms controlling the volume of a tissue that is enclosed in a rigid shell, possesses capillaries permeable for solutes, and has depressed autoregulation. ⋯ We contend that in the long run, the interstitial volume in such a tissue can be reduced only through reduction in arterial inflow pressure providing an otherwise optimal therapy to improve microcirculation. Therefore we argue, in contrast to the conventional view, that antihypertensive and antistress therapy may be of value by reducing the interstitial tissue volume during treatment of brain edema, and that the problem with ischemia during such therapy can be handled when considering an otherwise optimal intensive care. These physiologic principles of interstitial tissue volume regulation form the basic concept for the "Lund therapy" of severe head injuries, which is a new and controversial therapy of posttraumatic brain edema.
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After acute brain injury there may be increased intracranial production of cytokines, with activation of inflammatory cascades. We have sought to determine if a transcranial cytokine gradient was demonstrable in paired sera of 32 patients requiring intensive care after acute brain injury. ⋯ This suggests that there is significant production of IL-6 by intracranial cells after acute brain injury. Therapy directed towards combatting the negative effects of IL-6 may potentially benefit patients who have sustained an acute brain injury.
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Pediatric neurosurgery · May 1997
Intracranial neurological injuries associated with orbital fracture.
We attempted to define the central nervous system (CNS) concomitants of various types of orbital fractures in children by reviewing the records of 95 inpatients with admission diagnoses including orbital fracture who presented to the Children's National Medical Center from 1987 through 1994. Patients were divided into three age groups: group I: 0-5 years; group II: 6-12 years; group III: older than 12 years. Orbital fractures were classified by location: roof alone (A); orbital roof plus another orbital wall (B), and orbital fractures sparing the roof (C). ⋯ Seven of the patients with intracranial injury required emergent neurosurgical procedures. Younger children with maxillofacial injury sparing the orbital roof appear more likely to have coexisting intracranial injury, as reflected by CT findings and GCS on admission, than their older cohorts with similar injuries. Fracture of more than one orbital wall greatly increases risk of concurrent intracranial injury in all age groups.