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L F Marshall

Publications and source records attributed to L F Marshall.

At least 55 records · Page 3Linked to original sources
PubMed1991

Vegetative state after closed-head injury. A Traumatic Coma Data Bank Report.

To elucidate the clinical course of the vegetative state after severe closed-head injury, the Traumatic Coma Data Bank was analyzed for outcome at the time of discharge from the hospital and after follow-up intervals ranging up to 3 years after injury. Of 650 patients with closed-head injury available for analysis, 93 (14%) were discharged in a vegetative state. In comparison with conscious survivors, patients in a vegetative state sustained more severe closed-head injury as reflected by the Glasgow Coma Scale scores and pupillary findings and more frequently had diffuse injury complicated by swelling or shift in midline structures. Of 84 patients in a vegetative state who provided follow-up data, 41% became conscious by 6 months, 52% regained consciousness by 1 year, and 58% recovered consciousness within the 3-year follow-up interval. A logistic regression failed to identify predictors of recovery from the vegetative state.

Adolescent↗
PubMed1991

Intracranial hypertension in relation to memory functioning during the first year after severe head injury.

The relationship between intracranial hypertension and residual memory deficit after closed head injury was evaluated using the 6-month and 1-year neurobehavioral outcome data obtained by the Traumatic Coma Data Bank. Intracranial pressure was analyzed using the percentage of time that it exceeded 20 mm Hg and the maximum value recorded during the first 72 hours after injury. Memory measures included recall of word lists, prose recall, and visual memory for designs that were obtained 6 months (n = 149) and 1 year (n = 132) after injury. Intracranial hypertension occurred in more than half of the Traumatic Coma Data Bank cohort who met the criteria for the neurobehavioral follow-up study. Linear regression analysis disclosed an effect of elevated intracranial pressure on some, but not all, measures of memory at 6 months, whereas the results were negative for the 1-year follow-up examination. We conclude that the elevation of intracranial pressure exerts little if any effect on later memory functioning, and that any effect it does have diminishes over 1 year in survivors of severe head injury.

Adult↗
PubMed1991

Blunt injuries to the extracranial cerebral vessels associated with spine fractures.

Injury of the extracranial carotid or vertebral artery with associated spine fractures is a rare but documented entity. In this article, four cases are examined in which patients suffered axial fractures after motor vehicle accidents and subsequently were found to have pathology in one or more of the extracranial arteries. Misdiagnosis is a common complication because symptoms from this are often attributable to closed head injury. Early detection and treatment, however, are essential. As many as 40% of the cases reported have permanent neurologic deficit. Although cerebral angiography remains the diagnostic gold standard, other modalities (eg, transcranial doppler and magnetic resonance angiography) continue to be examined. The treatment of these lesions remains controversial. A variety of surgical procedures may be applicable depending on the time between the injury and the onset of symptoms, the location of the vascular injury, and the rapidity of diagnosis. Anticoagulation therapy appears to play a large role in the management of patients with injury of the extracranial carotid or vertebral artery.

Adult↗
PubMed1991

Management of head injury. Treatment of abnormal intracranial pressure.

Intracranial hypertension is recognized as a fundamental pathophysiologic process in brain injury. Although the exact pressure level defining intracranial hypertension remains to be firmly established, the majority of evidence available currently suggests that ICP should generally be treated when it exceeds 20 mm Hg. We suggest that lesions in the temporal lobe be treated at 15 mm Hg owing to the special relationship of this region to the brain stem. Along with the individual intracranial pressure reading, however, the course of the pressure over time and the status of the intracranial compliance as reflected in the ICP waveform must be considered when evaluating the intracranial dynamics. There is mounting evidence that patients with intracranial hypertension may comprise a heterogeneous group and that subgroups differ in their optimal treatment strategies. Although we cannot as yet identify such groups, factors such as age, CT diagnosis, responsiveness to hyperventilation, pressure-volume index, and ICP waveform are emerging as important differentiating factors. In particular, young patients with absent perimesencephalic cisterns and a tight brain on CT scan who manifest intracranial hypertension may comprise a group more suitable for treatment with hyperventilation and hypnotics than with osmotic agents. Although this is yet to be firmly established, currently it should be considered when such a patient responds poorly early in the course of conventional therapy for raised ICP. Treatment of intracranial hypertension remains rooted in the conventional therapeutic maneuvers. Maintenance of the basic homeostatic state of the patient is to be supplemented with head elevation, sedation, pharmacologic paralysis, hyperventilation, CSF drainage, and osmotic therapy as indicated. Outside of the special considerations discussed earlier, barbiturates should only be considered in patients with refractory intracranial hypertension without preexisting cardiovascular contraindications. Although several other agents have shown promise, currently the most exciting agent appears to be etomidate, which may prove quite useful. As ICP is better defined and understood, many significant and experimentally approachable questions are recognized. The basic mechanisms of raised ICP are slowly becoming elucidated. Clinical clues with which to subdivide patients with intracranial hypertension are being defined. New agents with efficacy in lowering raised ICP are appearing, and determination of their mechanisms of action may provide insight into the underlying disorder.

Brain Edema↗
PubMed1990

Large and small "holes" in the brain: reversible or irreversible changes in head injury.

We prospectively studied the frequency and course of large (greater than 25 cc) and small (less than 25 cc) areas of decreased density in 491 patients with severe closed head injury entered into the Traumatic Coma Data Bank (TCDB). The frequency of such areas and of subarachnoid haemorrhage on initial and subsequent CT scans were recorded. The frequency of large "holes" increased from 8 on the initial CT scan to 24 on scans done from day 4 to day 10. Half of these lesions either completely or almost completely resolved 14 days or more following injury. In patients with small "holes" the frequency increased from 24 to 77, but on scans performed 14 days or more following injury, 47% had completely disappeared. The presence of subarachnoid haemorrhage on the initial scan predicted the development of large areas of decreased density, but it did not predict the development of small areas of decreased density. The disappearance of a substantial number of these areas of decreased density ("holes") indicate that these areas do not necessarily represent areas of cerebral infarction. Patients with closed head injury are at risk for the development of what appear to be regional areas of cerebral ischaemia, but subarachnoid haemorrhage only predicts the development of large areas with these changes. Pharmacologic trials with calcium channel blocking agents or NMDA receptor antagonists in head injured patients appear warranted.

Brain↗
PubMed1990

Catecholamine and thyroid hormones in traumatic injury.

During hyperthyroidism, hypothyroidism, and severe stress there is often an inverse relationship between plasma norepinephrine (NE) and thyroid hormones. We evaluated this relationship in patients who were severely burned, patients who had injury to both brain and body, patients with head injury, and patients receiving high dose barbiturates for head injury. Head-injured patients had a low thyroxine (T4), low triiodothyronine (T3), and high reverse T3. Phenytoin for control of seizures lowered T3 and T4 and increased thyroid-stimulating hormone. Burned patients had a strong negative correlation between NE and T3 (r = -.88, p less than .001). Patients with injury to both brain and body had a weak negative correlation between NE and T3 (r = -.5, p = .06). Patients with head injury showed no correlation between NE and T3. Severely injured patients had a close inverse relationship between elevated NE levels and depressed T3 levels. This relationship appears to depend on an intact CNS, as the relationship was disrupted by head injury and barbiturates.

Adolescent↗
PubMed1990

Initial CT findings in 753 patients with severe head injury. A report from the NIH Traumatic Coma Data Bank.

In this prospective multicenter study, the authors have examined data derived from the initial computerized tomography (CT) scans of 753 patients with severe head injury. When the CT findings were related to abnormal intracranial pressure and to death, the most important characteristics of the scans were: midline shift: compression or obliteration of the mesencephalic cisterns: and the presence of subarachnoid blood. Diffuse hemispheric swelling was also found to be associated with an early episode of either hypoxia or hypotension.

Brain Injuries↗
PubMed1989

Determinants of head injury mortality: importance of the low risk patient.

Data were obtained prospectively for 7,912 head-injured patients admitted from 1980 to 1981 to 41 hospitals in 3 U.S. metropolitan areas. Highly significant independent predictors of mortality were motor score, number of reactive eyes, systolic blood pressure, abdominal injury, chest injury, age, and hospital unit (hospital or group of hospitals). The difference between the number of deaths observed and the number expected, by hospital unit, ranged from 43% below expectation to 52% above expectation. The 2 hospital units with the lowest mortality had only 1 death, where 9.4 would be expected, in patients whose risk of death was estimated to be less than 10%. In the single hospital with clearly excess mortality, however, the standardized mortality ratios were 208, 135, and 144% for the risk groups whose probabilities of death were 0 to 50, 50 to 80, and 80 to 100%, respectively. The lack of deaths in those hospitals with the best mortality experience and the excess mortality in the hospital with the worst mortality experience appear to be explained largely by differences in patients who, by clinical criteria, seem to be at low risk for death, and not by severely injured patients.

Adolescent↗
PubMed1989

Care of the multiply injured patient with cervical spine injury.

Cervical spine injuries can be disastrous. The treatment begins at the accident scene by obtaining an appropriate history, physical examination, and evaluation of the mechanics of the accident. Emergency medical stabilization takes precedence, but the cervical spine should be stabilized until an injury in this area is ruled out. If the patient has suffered a head injury or is violent, cervical spine precautions should be maintained until spinal column injuries have been ruled out roentgenographically. Because of the complexities of the evaluation and treatment of cervical spine injury in the multiply injured patient, an algorithm to assist in the management and evaluation of the patient has been developed, and a multidisciplinary, specialized evaluation and treatment team is employed. Through this approach, mortality in the multiply injured patient with a cervical spine injury has been reduced to 22%. Of 58 patients with cervical spine injuries evaluated by this aggressive approach, 14 patients had associated spine fractures, and 9 patients had positive peritoneal lavage requiring surgical exploration. Injuries involving other organ systems were also diagnosed and treated. Formal, rigid evaluation plans and aggressive multidisciplinary treatment are useful in saving the lives and salvaging neurologic function of these patients.

Algorithms↗
PubMed1988

Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury.

A series of 8814 head-injured patients admitted to 41 hospitals in three separate metropolitan areas were prospectively studied. Of these, 1906 patients (21.6%) were 14 years of age or less. This "pediatric population" was compared to the remaining "adult population" for mechanism of injury, admission Glasgow Coma Scale score, motor score, blood pressure, pupillary reactivity, the presence of associated injuries, and the presence of subdural or epidural hematoma. The relationship of each of these factors was then correlated with post-traumatic mortality. Except for patients found to have subdural hematoma and those who were profoundly hypotensive, the pediatric patients exhibited a significantly lower mortality rate compared to the adults, thus confirming this generally held view. This study indicates that age itself, even within the pediatric age range, is a major independent factor affecting the mortality rate in head-injured patients.

Adolescent↗
PubMed1988

High-dose barbiturate control of elevated intracranial pressure in patients with severe head injury.

In a five-center study, 73 patients with severe head injury and elevated intracranial pressure (ICP) were randomly assigned to receive either a regimen that included high-dose pentobarbital or one that was otherwise similar but did not include pentobarbital. The results indicated a 2:1 benefit for those treated with the drug with regard to ICP control. When patients were stratified by prerandomization cardiac complications, the advantage increased to 4:1. A multiple logistic model considering treatment and selected baseline variables indicated a significant positive treatment effect of barbiturates, a significant effect of time from injury to randomization, and an interaction of treatment with cardiovascular complications. However, of 925 patients potentially eligible for randomization, only 12% met ICP randomization criteria. The results support the hypothesis that high-dose pentobarbital is an effective adjunctive therapy, but that it is indicated in only a small subset of patients with severe head injury.

Adolescent↗
PubMed1988

A modified technique for cervical facet fusions.

Posterior facet fusion of the cervical spine has been described in the literature as a method of obtaining fusion when posterior elements are deficient because of previous laminectomy or trauma. The technique, as originally described, includes anchoring autologeneic struts of corticocancellous bone to the cervical spine with wires passed through drill holes in the inferior articular facets around the struts of bone graft. When long facet fusions are required, however, it may be impossible to obtain adequate length and shape of the grafts to bridge the desired fusion area. A technique is described that eliminates this problem by substituting thin Harrington compression rods for the autologeneic corticocancellous struts, and using cancellous and corticocancellous bone graft to achieve fusion.

Adolescent↗
PubMed1987

Neurobehavioral outcome following minor head injury: a three-center study.

The majority of hospital admissions for head trauma are due to minor injuries; that is, no or only transient loss of consciousness without major complications and not requiring intracranial surgery. Despite the low mortality rate following minor head injury, there is controversy surrounding the extent of morbidity and the long-term sequelae. The authors postulated that consecutively admitted patients who fulfilled research diagnostic criteria for minor head injury and who were carefully screened for antecedent neuropsychiatric disorder and prior head injury would exhibit subacute cognitive and memory deficits that would resolve over a period of 1 to 3 months postinjury. To evaluate this hypothesis, the neurobehavioral functioning of 57 patients was compared within 1 week after minor head injury (baseline) and at 1 month postinjury with that of 56 selected control subjects at three medical centers. Quantified tests of memory, attention, and information-processing speed revealed that neurobehavioral impairment demonstrated at baseline by all means of measurement generally resolved during the first 3 months after minor head injury. Although nearly all patients initially reported cognitive problems, somatic complaints, and emotional malaise, these postconcussion symptoms had substantially resolved by the 3-month follow-up examination. The data suggest that a single uncomplicated minor head injury produces no permanent disabling neurobehavioral impairment in the great majority of patients who are free of preexisting neuropsychiatric disorder and substance abuse.

Adolescent↗
PubMed1987

Deterioration following spinal cord injury. A multicenter study.

The results are presented of a prospective study of the course of 283 spinal cord-injured patients who were consecutively admitted to five trauma centers participating in the Comprehensive Central Nervous System Injury Centers' program of the National Institutes of Health. Of the 283 patients, 14 deteriorated neurologically during acute hospital management. In 12 of the 14, the decline in neurological function could be associated with a specific management event, and in nine of these 12 the injury involved the cervical cord. Nine of the 14 patients who deteriorated had cervical injuries, three had thoracic cord injuries, and two had thoracolumbar junction injuries. Management intervention was identified as the cause of deterioration in four of 134 patients undergoing operative intervention, in three of 60 with skeletal traction application, in two of 68 with halo vest application, in two of 56 undergoing Stryker frame rotation, and in one of 57 undergoing rotobed rotation. Early surgery on the cervical spine when cord injury is present appears hazardous, since each of the three patients with a cervical cord injury who deteriorated was operated on within the first 5 days. No such deterioration was observed following surgery performed from the 6th day on. In two other patients, deterioration did not appear to be related to management but was a direct product of the underlying disease or of systemic complications. Deterioration following hospitalization for spinal cord injury is relatively uncommon--4.9% in this large series. In most instances, decline in function could be attributed to specific management procedures. These changes must not be interpreted as representing failure to provide optimal care but rather should be seen as the inevitable product of an attempt to manage patients with spinal cord and column injuries, many of which are clearly unstable.

Humans↗