Pituitary adenoma presenting as unilateral proptosis.
Explore the source record for details and available documents.
Adenoma↗
Biomedical subjects
S C Stein
Publications and source records attributed to S C Stein.
Delayed brain injury after head trauma: significance of coagulopathy.
We reviewed the records of 253 patients with head injury who required serial computed tomographic (CT) scans; 123 (48.6%) developed delayed brain injury as evidenced by new or progressive lesions after a CT scan. An abnormality in the prothrombin time, partial thromboplastin time, or platelet count at admission was present in 55% of the patients who showed evidence of delayed injury, and only 9% of those whose subsequent CT scans were unchanged or improved from the time of admission (P less than 0.001). Among patients developing delayed injury, mean prothrombin time at admission was significantly longer (14.6 vs. 12.6 s, P less than 0.001) and partial thromboplastin time was significantly longer (36.9 vs. 29.2 s, P less than 0.001) than patients who did not have delayed injury. If coagulation studies at admission were normal, a patient with head injury had a 31% risk of developing delayed insults. This risk rose to almost 85% if at least one clotting test at admission was abnormal (P less than 0.001). We conclude that clotting studies at admission are of value in predicting the occurrence of delayed injury. If coagulopathy is discovered in the patient with head injury early follow-up CT scanning is advocated to discover progressive and new intracranial lesions that are likely to occur.
Adolescent↗
Moderate head injury: a guide to initial management.
The purpose of this study is to determine the initial treatment of patients who appear to have sustained moderate head injuries when first evaluated. The authors reviewed the records of 341 patients whose initial Glasgow Coma Scale (GCS) scores ranged from 9 to 12, as well as another 106 patients with GCS scores of 13. All patients underwent cranial computerized tomography (CT) at the time of admission. In 40.3% of these patients the CT scans were abnormal (30.6% had intracranial lesions), and 8.1% required neurosurgical intervention (craniotomies for hematoma in 12, elevation of depressed fractures in five, and insertion of intracranial pressure monitors in 19). Four patients died of their intracranial injuries. A similar incidence of lesions found on CT and at surgery suggests that an initial GCS score of 13 be classified with the moderate head injury group. Skull fractures were found to be poor indicators of intracranial abnormalities. These results suggest that all patients with head injury thought to be moderate on initial examination be admitted to the hospital and undergo urgent CT scanning. Patients with intracranial lesions require immediate neurosurgical consultation, surgery as needed, and admission to a critical-care unit. Scans should be repeated in patients whose recovery is less rapid than expected and in all patients with evidence of clinical deterioration; this was necessary in almost half of the patients in this group, and 32% were found to have progression of radiological abnormalities on serial CT scans.
Craniocerebral Trauma↗
Mild head injury: a plea for routine early CT scanning.
We reviewed the records of 1538 mild head injury patients admitted during a 4 1/2-year period to the Southern New Jersey Regional Trauma Center. All patients had experienced brief loss of consciousness or amnesia, but had a normal or near normal neurologic examination on admission, with Glasgow Coma Scale (GCS) scores of 13-15 and no focal neurologic deficit. Routine urgent cranial CT scans were obtained on all patients, and correlations between skull fractures and intracranial lesions investigated. Two hundred sixty-five patients (17.2%) harbored 340 lesions on CT scans, of which 131 were fractures and 209 were intracranial abnormalities. Fifty-eight patients needed surgery for their intracranial lesions; 23 of them had no skull fractures. None of the 1339 patients without CT evidence of intracranial lesions deteriorated under observation. We conclude that clinical observation with or without skull x-ray films is inadequate to rule out potentially dangerous intracranial lesions in apparently mild head injuries. If there is a history of loss of consciousness or amnesia, an immediate CT scan is indicated. If the results of the CT scan are normal and there are no other indications for admission, these patients may be safely discharged.
Craniocerebral Trauma↗
Is routine computed tomography scanning too expensive for mild head injury?
OBJECTIVE: To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission. DESIGN: Retrospective record review, hypothetical costs based on actual patient course and requirements. SETTING: Southern New Jersey Regional Trauma Center at Cooper Hospital/University Medical Center. PARTICIPANTS: 658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans. MEASUREMENTS: Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols. MAIN RESULTS: The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was $1,207. If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions. CONCLUSIONS: Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.
Adolescent↗
Time of rehabilitation admission and severity of trauma: effect on brain injury outcome.
Outcome after traumatic brain injury, defined by the Glasgow Outcome Scale (GOS) and length of stay in acute rehabilitation, was measured in 59 patients admitted to an intensive rehabilitation program to examine the effects of severity of the initial brain injury, severity of multiple trauma, and length of stay in the acute care hospital. Severity of initial brain injury, best measured by length of coma, was the most significant predictor of GOS outcome. Length of acute hospitalization was a small, but significant, predictor of GOS. Severity of initial brain injury, length of acute hospitalization, and gender emerged as predictors of length of rehabilitation hospital stay. Although length of acute hospitalization is apparently affected by severity of brain injury, it adds significantly--more than severity of brain injury--to the prediction of length of rehabilitation.
Adolescent↗
The value of computed tomographic scans in patients with low-risk head injuries.
The determination that a particular head injury is "mild" or "low-risk" is usually made on clinical grounds. Observation at home or in the hospital has been the usual treatment for such patients. A recent report of excessive mortality among these patients with low-risk head injuries in some hospital settings suggests the need for improvement in diagnostic criteria. Our study included 658 patients admitted to Cooper Hospital for a mild head injury, who had a Glasgow Coma Scale score of 13 to 15 on admission, and who experienced a brief loss of consciousness or amnesia after the injury. Their records and cranial computed tomographic (CT) scans on admission were reviewed to determine their subsequent course. In 18% of patients abnormalities were seen on the initial CT scan and 5% required surgery. Among the 62 patients with a Glasgow Coma Scale score of 13, 40% had abnormalities on the CT scan and 10% required surgery. None of the 542 patients with normal CT scans on admission showed subsequent deterioration and none needed surgery. These figures suggest that history and physical examination alone are not adequate to assess head injury or severity of risk and that the addition of a CT scan greatly improves patient assessment. Abnormalities on CT scans are so common in patients with a Glasgow Coma Scale score of 13 that head injuries in these patients should be classified as "moderate" rather than "mild" in severity and risk. Patients with normal CT scans should be considered for observation at home, allowing hospital personnel to devote full attention to the more seriously injured patients.
Brain Injuries↗
Prediction of outcome of shunt procedures for communicating hydrocephalus.
Explore the source record for details and available documents.
Adult↗
Adult hydrocephalus and shunting.
Explore the source record for details and available documents.
Adult↗
Concomitant strabismus as a sign of intracranial disease.
A child with a postoperative residual estropia of 16 diopters was suddenly found to have 75 D of esotropia for distance and 65 D of estropia for near. Full versions were noted that would be inconsistent with sixth nerve palsy. Divergence palsy is characterized by a substantially larger convergent strabismus for distance that, in this case, was only 10 D. One is left with the conclusion that concomitant strabismus may indicate the onset of intracranial disease that, in this case, was caused by an arteriovenous malformation.
Brain Edema↗
Chronic mycotic meningitis with spinal involvement (arachnoiditis): a report of five cases.
Five patients developed mycotic spinal arachnoiditis-meningitis causing signs and symptoms of spinal cord neoplasm. Four had cryptococcal infection, the fifth had aspergillosis. In three patients, diagnosis was made at surgery; all three developed acute fungal meningitis postoperatively and two died. The diagnosis was made nonsurgically in two patients and was followed by medical cure. These five and twelve other reported patients with mycotic spinal arachnoiditis shared features that suggested the diagnosis. In contrast to most patients with spinal tumors, those reported here tended to be young (mean age, 32 years), to lack evidence for a primary tumor, and to have a fluctuating history of spinal symptoms for several months. Frequent associated findings were recent pregnancy; the abuse of alcohol, narcotics, or both; and the presence of headache and fever. Plain roentgenograms of the spine were normal. No single finding was diagnostic, but the combination of several would be rare with spinal tumor.
Adult↗
The prevalence of neural tube defects among ethnic groups in Brooklyn, New York.
Records of almost 174,000 consecutive births at six Brooklyn hospitals during the years 1968-1976 were reviewed for congenital neural tube defects. Prevalence of anencephaly, myelomeningocele and occipital encephalocele combined was significantly higher in infants delivered to mothers born in Puerto Rico than in offspring of non-Puerto Rican whites or blacks. The association of prevalence rates with ethnicity remained significant after adjustment for several variables. However, when adjustment was made for private or service status the difference between Puerto Ricans and whites, although still appreciable, was no longer statistically significant. No significant differences in prevalence rates between whites and blacks were observed. Sex ratios of affected infants were close to unity in each ethnic group. Statistically significant associations were found between the prevalence of neural tube defects and parity, gravidity and economic status. The patterns of these associations varied among the ethnic groups. A declining trend in the prevalence of myelomeningocele was observed for all ethnic groups.
Black People↗
Is myelomeningocele a disappearing disease?
The incidence of major congenital anomalies of the central nervous system was determined in a study of more than 233,000 births in Brooklyn, New York hospitals during the years 1968 to 1979. Anencephaly, myelomeningocele, and hydrocephalus occurred at frequencies of 47.1, 42.4, and 49.3 cases per 100,000 total births, respectively. During the 12 years of the study, the incidence of myelomeningocele decreased at a linear rate of approximately 4.6 cases per 100,000 births per year. A review of comparable reports on births in the northeastern region of the United States shows that a relatively consistent linear decline in myelomeningocele incidence has been proceeding at this rate for the past 50 years. It is concluded that minor local fluctuations and variability in data collection have obscured the steady decrease in occurrence. No significant declines were seen in the incidence rates of anencephaly or hydrocephalus, nor were uniform secular trends for these anomalies evident from previous reports. Epidemiologic differences between myelomeningocele and anencephaly are noted and their common etiology is questioned.
Anencephaly↗
Tracer clearance studies in hydrocephalus: a critique.
Quantitative isotope ventriculography (QIV) has been suggested as a method for diagnosing hydrocephalus and predicting the results of CSF shunt insertion. However, the physiological significance of this and other tracer clearance studies is questionable. Using a simplified mathematical model for tracer clearance following ventricular injection, a series of isotope retention curves were generated by an IBM 360-40 computer. The author shows that the tracer clearance from the CSF is just as dependent on the volume of the CSF compartment as it is on the rate of CSF absorption. This means, for example, that doubling the CSF volume without diminishing absorption (cerebral atrophy) yields the same results as halving the absorption rate in patient with normal CSF volume (early hydrocephalus). In order for tracer clearance studies to measure CSF absorption, to determine the presence of hydrocephalus, and to predict the results of shunting, an accurate measure of CSF volume must be obtained.
Absorption↗
Pathogenesis of congenital midline porencephaly.
A recent report in this journal described 5 children with holoprosencephaly, parietal scalp anomalies and midline intracranial cysts. The authors coined the term 'congenital midline porencephaly' for the clinical syndrome and described the cysts as diverticula of hydrocephalic lateral ventricles. This report describes 3 further children with the same syndrome. The author proposes that the midline cyst is simply a variant of the dorsal cyst reported in other cases of holoprosencephaly. It is further concluded that the cyst arises from primary dysgenesis of cerebral midline structures and is not the result of hydrocephalus. The monoventricle and cyst in these children have the CT scan appearance of the head of a primitive arrow. This 'arrowhead' sign may be helpful in the diagnosis of holoprosencephaly with congenital midline porencephaly.
Brain Diseases↗
Intracranial developmental cysts in children: treatment by cystoperitoneal shunting.
The author presents the results of primary cystoperitoneal shunting in 12 infants and children with developmental cysts in various intracranial locations. Preoperative studies were done in each child to rule out a brain tumor as the cause of the cyst and to determine whether communication existed between the cyst and the subarachnoid space. The ventricular system was also shunted in children with both noncommunicating cysts and hydrocephalus. Except for 2 children with other operation was needed during a mean follow-up period of 2.2 years. The reasons to recommend shunt insertion as the primary treatment for developmental cysts in children include safety, ease, and a high rate of success compared to attempted excision.
Arachnoid↗
A noninvasive approach to quantitative measurement of flow through CSF shunts. Technical note.
A method of measuring flow rate through cerebrospinal fluid (CSF) shunts is reported. It consists of two thermistors in series applied to the skin over the shunt tubing. The thermistors respond by a drop in measured temperature following application of an ice cube placed on the skin overlying the proximal shunt tube. The time required for the thermal response to travel between the two thermistors is related to the velocity of flow through the shunt tubing. Flow rate can then be calculated using the internal diameter of the tubing. A series of animal experiments employing a constant infusion of mock CSF through subcutaneously implanted shunt tubing showed excellent correlation between calculated flow rates and actual infusion rates. The device is noninvasive and easily adapted to use in patients. The measurements are readily repeatable.
Animals↗