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Purpose The purpose of this study was to assess the diagnostic sensitivity, specificity, accuracy, negative predictive value (NPV), positive predictive value (PPV), and test-retest reliability of magnetic resonance imaging (MRI) for detecting cartilage abnormalities of the glenohumeral joint in comparison with the gold standard of diagnostic arthroscopy. Methods Forty-four patients with a preoperative non-contrast MRI study of their affected shoulder underwent arthroscopy by one surgeon for rotator cuff tendinopathy from 2009 to 2010. Articular cartilage defects were prospectively recorded and graded according to the International Cartilage Repair Society classification system at the time of arthroscopy. One year after surgery, the preoperative MRI were reviewed by a board-certified radiologist and the treating surgeon for articular cartilage defects of both the humeral head and the glenoid. Sensitivity, specificity, accuracy, and test-retest reliability were calculated. Results At arthroscopy, 43% of the shoulders were found to have articular cartilage defects. When the readers' findings were combined, the sensitivity of detecting humeral lesions on MRI was 32%; specificity, 80%; accuracy, 63%; PPV, 57%; and NPV, 66%. The sensitivity of detecting glenoid lesions was 31%; specificity, 86%; accuracy, 76%; PPV, 33%; and NPV, 85%. Conclusions This study finds that the overall accuracy of MRI in detecting articular cartilage damage in patients with the clinical diagnosis of subacromial pathology is moderate. Level of Evidence Level II, development of diagnostic criteria based on consecutive patients with universally applied reference "gold" standard.

Background The primary objective of this study was to compare the overall survival (OS) of patients with anaplastic astrocytoma (AA) treated with radiotherapy (RT) and either temozolomide (TMZ) or a nitrosourea (NU). Secondary endpoints were time to tumor progression (TTP), toxicity, and the effect of IDH1 mutation status on clinical outcome. Methods Eligible patients with centrally reviewed, histologically confirmed, newly diagnosed AA were randomized to receive either RT+TMZ (n = 97) or RT+NU (n = 99). The study closed early because the target accrual rate was not met. Results Median follow-up time for patients still alive was 10.1 years (1.9-12.6 y); 66% of the patients died. Median survival time was 3.9 years in the RT/TMZ arm (95% CI, 3.0-7.0) and 3.8 years in the RT/NU arm (95% CI, 2.2-7.0), corresponding to a hazard ratio (HR) of 0.94 (P = .36; 95% CI, 0.67-1.32). The differences in progression-free survival (PFS) and TTP between the 2 arms were not statistically significant. Patients in the RT+NU arm experienced more grade ≥3 toxicity (75.8% vs 47.9%, P < .001), mainly related to myelosuppression. Of the 196 patients, 111 were tested for IDH1-R132H status (60 RT+TMZ and 51 RT+NU). Fifty-four patients were IDH negative and 49 were IDH positive with a better OS in IDH-positive patients (median survival time 7.9 vs 2.8 y; P = .004, HR = 0.50; 95% CI, 0.31-0.81). Conclusions RT+TMZ did not appear to significantly improve OS or TTP for AA compared with RT+ NU. RT+TMZ was better tolerated. IDH1-R132H mutation was associated with longer survival.

Diagnostic methods and biomarkers of early disc degeneration are needed as emerging treatment technologies develop (e.g., nucleus replacement, total disc arthroplasty, cell therapy, growth factor therapy) to serve as an alternative to lumbar spine fusion in treatment of low back pain. We have recently demonstrated in cadaveric human discs an MR imaging and analysis technique, spin-lock T(1rho)-weighted MRI, which may provide a quantitative, objective, and non-invasive assessment of disc degeneration. The goal of the present study was to assess the feasibility of using T(1rho) MRI in vivo to detect intervertebral disc degeneration. We evaluated ten asymptomatic 40-60-year-old subjects. Each subject was imaged on a 1.5 T whole-body clinical MR scanner. Mean T(1rho) values from a circular region of interest in the center of the nucleus pulposus were calculated from maps generated from a series of T(1rho)-weighted images. The degenerative grade of each lumbar disc was assessed from conventional T(2)-weighted images according to the Pfirmann classification system. The T(1rho) relaxation correlated significantly with disc degeneration (r=-0.51, P0.01) and the values were consistent with our previous cadaveric study, in which we demonstrated correlation between T(1rho) and proteoglycan content. The technique allows for spatial measurements on a continuous rather than an integer-based scale, minimizes the potential for observer bias, has a greater dynamic range than T(2)-weighted imaging, and can be implemented on a 1.5 T clinical scanner without significant hardware modifications. Thus, there is a strong potential to use T(1rho) in vivo as a non-invasive biomarker of proteoglycan loss and early disc degeneration.

✓ Generalized dystonia is one of the most disabling movement disorders. Ablative stereotactic surgery such as pallidotomy has been performed for medically refractory dystonia. Recently, deep brain stimulation (DBS) has appeared as an alternative to ablative procedures. Nevertheless, there have been few published reports detailing improvement in dystonia with DBS. This 36-year-old man with Hallervorden—Spatz syndrome suffered from intractable primary generalized dystonia for 28 years. He was completely dependent for activities of daily living and wheelchair bound because of continuous severe dystonic movements in the face, tongue, neck, trunk, and upper and lower extremities while at rest. The Burke-Fahn-Marsden (BFM) Dystonia Rating Scale score was 112 (maximum 120 points). Bilateral DBS of the globus pallidus internus was performed and resulted in marked improvement in motor functioning and dystonic symptoms with a significant reduction in disability. The BFM score improved to 22.5 points (80% improvement) at 3 months postsurgery and the patient's dystonia was still well suppressed 1 year after surgery. Bilateral pallidal stimulation is an effective and safe treatment for intractable generalized dystonia in Hallervorden—Spatz syndrome, even if the disability is severe and longstanding.

Study design The authors of this prospective study examined the preoperative and 3-year postoperative magnetic resonance images of 14 patients undergoing anterior and posterior fusion and/or posterior fusion only for scoliosis. All magnetic resonance images were ready by two independent neuroradiologists, who were blinded to the purposes of the study, for the presence of disc narrowing, signal decrease on T2, or herniated nucleus pulposus before and after surgery. Particular attention was paid to the disc changes at the level directly below the end vertebral level of the fusion and two levels below the fusion in the lumbosacral spine existing before surgical intervention. Objectives To evaluate the potential for disc degeneration distal to long scoliosis fusions with end fusion levels in the mid to lower lumbar spine. Summary of background data The determination of end levels of fusion for contructs presently used to manage adult scoliotic deformity has been evaluated in terms of correction of curvature and late decompensation in coronal and sagittal plane balance after fusion. However, the natural history of the caudal, free-motion segments in terms of degeneration and/or correlation with pain has not yet been addressed. Methods Fourteen patients undergoing scoliosis fusion underwent magnetic resonance imaging before surgery and approximately 3 years after surgery. The scans were reviewed by two independent neuroradiologists who looked at three degenerative indices at the disc below the area of scoliosis fusion. The authors analyzed rates of change of the three degenerative indices in the pre- and postoperative magnetic resonance images and created associations between the observed changes on the magnetic resonance images and the clinical outcomes of pain, the presence or absence of solid fusion, and the need for repeat surgery. Results Estimates of the rates of change of the three degenerative indices one or two levels below the fusion were as follow: the chance of disc narrowing, .2-34%; the chance of a decreasing signal on T2, 5-54%, with a 23% incidence among this group; and the chance of herniated nucleus pulposus, 0-34%. There was a significant correlation between the presence of back and/or leg pain and the signal decrease one level below the fusion (P = .04). Conclusions If these results are corroborated in a larger sample size, surgeons who manage deformity may have to consider altering fusion levels at the time of fusion based on magnetic resonance imaging predictors. The present data may help to inform patients about the risk of developing junctional degenerative changes and potential symptoms from these changes below scoliosis fusions.

2002 Background: TMZ is efficacious in recurrent anaplastic glioma and newly diagnosed glioblastoma. The primary objective was to compare the overall survival (OS) of patients with AA treated with ...

Purpose To determine the safety and toxicity of carmustine (BCNU) and temozolomide (TMZ) with radiotherapy (RT) in newly diagnosed anaplastic astrocytoma. Methods and materials Patients >18 years old with anaplastic astrocytoma, a Karnofsky performance status score of ≥60, and adequate pulmonary function were eligible. All patients provided informed consent. Standard RT started within 5 weeks of diagnosis. In both arms, 150 mg/m 2 of TMZ was given on Days 1–5 of RT. In Arm 1, 200 mg/m 2 of carmustine was given on Day 1 of RT. In Arm 2, 150 mg/m 2 of carmustine was given on Day 5 of RT. After RT, TMZ and carmustine were repeated for a total of six cycles. Results A total of 15 and 14 patients were enrolled in the two pilot arms. Because of hematologic and pulmonary toxicities, dose reductions by the second cycle of therapy occurred in >70% of the patients in Arm 1 and >50% in Arm 2 despite a reduction in the carmustine dose. Conclusion The results of these pilot studies have implications for the design of studies testing the initial treatment of brain tumors. Because of the poor tolerance of the combination, the multicooperative group Phase III study consists of two randomized arms of single-agent carmustine vs. single-agent TMZ.

Background Extraaxial cavernous hemangiomas (cavernomas) are very rare lesions, and less than 20 descriptions of these lesions outside the middle fossa have been reported. In this report, we describe a dural cavernous angioma involving the posterior sagittal sinus and discuss the clinical, radiological, operative, and histological features of this very uncommon lesion. Case Description A 31-year-old right-handed male presented with headache and decreasing visual acuity. Severe bilateral papilledema was found on fundoscopic examination. Neurological examination demonstrated a minor right temporal field cut. Brain magnetic resonance imaging with contrast demonstrated a 2.5 × 2.5 cm hyperintense enhancing mass in the midline, which was contiguous with the posterior margin of the falx cerebri. The patient underwent a bilateral occipital craniotomy centered on the lesion. The histological features were consistent with cavernous angioma. Conclusion This report demonstrates that although extra axial cavernomas are quite rare, they must be included in the differential diagnosis of enhancing lesions along the posterior sagittal sinus. The operative removal of these lesions can be quite treacherous and usually requires a careful reapproximation of the patent sinus after lesion excision.

We report a 42-year-old man with a rare carpal tunnel syndrome (CTS) secondary to an osteophyte of the trapezium. The patient presented with a 3-year history of CTS, consisting of progressive pain and paresthesias in his right hand, positive Tinel and Phalen signs, and an electrodiagnostic study demonstrating median nerve compression at the wrist. The procedure was an open carpal tunnel release. Intraoperatively, a bony protuberance was found beneath the transverse carpal ligament (TCL), resulting in compression of the median nerve. The median nerve was decompressed and the patient's symptoms resolved postoperatively. Surgical pathology revealed bony fragments, and a postoperative CT scan was supportive of an osteophytic remnant protruding from the trapezium. Carpal bone osteophytes are rarely reported causes of CTS.

A man with shoulder pain and complaints of weakness had examination findings consistent with a suprascapular neuropathy with predominant involvement of the infraspinatus muscle. Electrodiagnostic studies confirmed an axon-loss suprascapular neuropathy with greater involvement of the infraspinatus muscle. Magnetic resonance imaging (MRI) demonstrated a large ganglion cyst originating from the glenohumeral joint. The clinical, electrodiagnostic, and radiologic evaluation of suprascapular neuropathy is discussed.

We used computerized tomographic scans and subsequent dissections to evaluate the position of ninety pedicle screws that had been inserted bilaterally into the fourth through twelfth thoracic vertebrae of five fresh-frozen cadavera. The screws had been inserted by five experienced spine surgeons without the use of radiographs or imaging studies. Of the ninety screws, thirty-seven were found to have penetrated the cortex of the pedicle. Twenty-one screws had penetrated the medial cortex and entered the spinal canal, and sixteen had penetrated the lateral cortex. The aorta and the esophagus were at greatest risk for injury after advancement of the screws beyond the anterior vertebral cortex. Computerized tomographic scans of the thoracic spine in nineteen living controls who did not have a spinal abnormality confirmed the proximity of the posterior mediastinal structures to the misplaced screws.

Spinal canal and dural sac morphometry as demonstrated by CT scan analysis in patients undergoing chemonucleolysis for the treatment of herniated lumbar discs was analyzed in an attempt to develop a method of predicting positive or negative follow-up clinical results. The morphometry of the canal and dural sac at the intervertebral disc level was defined by reviewing normal levels of CT scans. Levels with herniated discs were then analyzed for comparison of treatment results between successful and unsuccessful procedures. The concept of spinal reserve capacity was evaluated. Significant differences between canal morphometric parameters of patients with treatment success or failure were then identified. The concept of spinal reserve capacity may be applicable in spinal stenosis, but we were unable to delineate any predictive value in the evaluation of patients with herniated lumbar discs undergoing chemonucleolysis.

Distinction between spinal tumors and infections is a frequent clinical dilemma. To assess the accuracy of magnetic resonance imaging in distinguishing between spinal tumors and spinal infections, 30 patients with proven spinal tumors or infections were studied. Magnetic resonance imaging correctly diagnosed spinal tumors and infections in 29 of 30 cases (97%): 21 of 22 tumors were correctly diagnosed, and 8 of 8 infections were correctly diagnosed. The following points were learned: 1) The most consistent finding of vertebral osteomyelitis was the involvement of the disc space and adjacent vertebral body with decreased signal intensity on the T1-weighted images and increased signal intensity on the T2-weighted images. On the contrary, the disc spaces in tumor cases were uninvolved and demonstrated normal intensities on both T1- and T2-weighted images. 2) Loss of definition of the vertebral endplate was more common with infection than with tumor. 3) Contiguous vertebral involvement was seen more frequently in infections than in tumors. 4) Soft tissue changes were quite helpful: fat planes were obscured diffusely due to edema in infection, whereas fat planes were frequently intact, or obscured only focally, in tumors. 5) Cord compression was accurately diagnosed by magnetic resonance imaging in both tumors and infections. Magnetic resonance imaging was found to be superior to other imaging modalities in its ability to detect tumors or infections early and in providing information on the bone, disc, soft tissue, and neural structures.

The computed comographic and clinical findings in 17 patients with fatty intracranial tumors and in 10 patients with epidermoid tumors, all of maldevelopmental origin, are presented. Fat was found in linomas (the most frequent), dermoids, and teratomas. Differentiation between these tumors is discussed on the basis of density, calcification, location and symptomatology.

One hundred twenty-two patients with surgically confirmed pathology consisting of either herniated lumbar disc, spinal stenosis, or both were included in this investigation. For each of these patients, preoperative metrizamide myelography and computerized tomography were performed. Each myelogram and CT scan was read blindly so that the neuroradiologist interpreting the study had no knowledge of the patient's surgical pathology, clinical examination, nor any knowledge of the interpretation of the other preoperative test. A painstaking attempt was made to describe precisely both the exact nature of the preoperative myelogram and CT scan interpretations. The correlations between the preoperative interpretation of each test and the observed surgical findings then were analyzed statistically. Based upon this analysis, myelography was found to be more accurate than computed tomography in the diagnosis of herniated lumbar disc (83% vs. 72%). In the diagnosis of spinal stenosis, myelography was slightly more accurate than computed tomography (93% vs. 89%). Based upon the results of this study, the authors conclude that metrizamide myelography is more accurate than computed tomography in the diagnosis of both herniated lumbar disc and spinal stenosis and remains the diagnostic study of choice for these conditions. Furthermore, metrizamide myelography gives the added advantage of visualizing the thoracolumbar junction and, thus, affords the opportunity to diagnose occult spinal tumors.

General cerebral swelling was the most common CT finding in 100 pediatric patients with acute head injury, and was demonstrated by CT as absence or compression of the lateral and third ventricles and perimesencephalic cisterns. Up to 50% of the children who die from head injury are conscious on admission. The most common pathological findings are diffuse cerebral swelling, loss of cerebrospinal fluid spaces, and venous congestion of the cortex.

Hemorrhagic contusion was the most frequent focal parenchymal abnormality demonstrated in a series of 304 acute closed head injury patients studied by sequential computed tomography (CT). It was identified in 70 patients (23%) and was 3 times as frequent in adults as in children. In 41% of these cases there were other significant lesions present, most commonly an acute subdural hematoma. The contusion itself may produce symptoms acutely as well as permanent focal neurologic deficits. The time course of the hemorrhagic contusion, as revealed by CT, correlates with the four neuropathologic stages of the contusion. The hemorrhagic contusion differs from the intracerebral hematoma both in its initial CT appearance and in the pattern of resolution.

Transsphenoidal surgery produces changes in the paranasal sinuses and sella that should be familiar to radiologists in view of the frequency of this type of surgery. Some of these changes, such as soft-tissue-density debris in the sinuses, are transient. Fat and other packing material identifiable in the sinuses and sella after surgery is permanent. The procedure is associated with a variety of complications that are readily detectable by computed tomography (CT). These include bleeding, compression of parasellar structures by packing material, cerebrospinal fluid leaks, and pneumocephalus. After a transsphenoidal procedure, with or without follow-up radiation therapy, residual enhancing intrasellar and parasellar lesions may still be identified.

Of 109 children examined by cranial computed tomography soon after an acute head injury, a density in the region of the falx was identified in 24 patients, but disappeared on subsequent studies. The density measures in the range of blood and is thought to represent subarachnoid blood. It can be confused with falx calcification in adolescents and adults, but falx calcification is normally not seen in the pediatric population.

✓ Noninvasive studies of regional cerebral blood flow (CBF) were performed on 36 head-injured patients in varying degrees of coma, using the intravenous xenon-133 method. Serial examinations, averaging four per patient, were begun during the acute phase of illness and continued until death or recovery of normal consciousness. Comparison of the initial and final studies revealed that CBF declined to very low levels in all nine patients who died, and remained subnormal in a patient with persistent vegetative state. In contrast, 25 of 26 patients who recovered consciousness showed increases in blood flow. Because of the presence of both reduced and elevated blood flows on the initial study, CBF was not predictive of outcome. Absolute or relative hyperemia, observed in nine acute cases, was associated with either diffuse cerebral swelling (observed on computerized tomography) or recovery from systemic shock. Cerebral metabolic studies in hyperemic patients yielded a very low oxygen uptake and arteriovenous oxygen difference, indicating that the high blood flow was a true “luxury perfusion.” When instances of presumed luxury perfusion were excluded, CBF was positively correlated with level of consciousness, assessed on a four-point coma scale.

One hundred nine head-injured patients with epidural and acute and chronic subdural hematomas were evaluated by computed tomography (CT). Eighty-two patients had subsequent CT examinations in order to evaluate postoperative changes and responses to therapy. Results seen on CT studies were compared to patients' neurologic status at the time of scanning. The rapid return of the appearance of the brain and the patients' neurologic status to normal soon after evacuation of an uncomplicated epidural hematoma reflect the lack of parenchymal damage. In contrast, acute subdurals are usually produced by associated contusions or cortical lacerations. The mass effect of these parenchymal lesions is responsible for a degree of ventricular shift out of proportion to the usual small size of the acute subdural. Small acute subdurals managed medically and residual collections found after evacuation resolved spontaneously. No acute subdurals progressed to a chronic subdural. The latter are infrequently associated with cerebral parenchymal injury and their symptoms are due to the size of the collections. Deformity of the underlying brain by the chronic process and slow re-expansion of the brain account for the common finding of a slowly resorbing, residual fluid collection following surgical evacuation.

Neuropsychological outcome within two years after injury was determined in 159 head injured patients who were classified into three groups according to the presence of either unilateral, bilateral, or no visual field defects (VFDs). The VFDs occurred irrespective of injury severity as determined by the Glasgow coma scale, or social outcome as determined by the Glasgow outcome scale. Differences among the three visual field groups were obtained for several neuropsychological functions: intelligence, memory, learning, acquired verbal skills, visuospatial skills, and visuomotor speed. Patients with bilateral VFDs were more severely impaired neuropsychologically than those with unilateral or no VFDs. Occurrences of secondary complications (brain swelling, intracranial hypertension, and hyperemia) were more prevalent among the bilateral VFD cases. The findings suggested that bilateral VFDs may be indicators of increased brain damage from secondary insults.

Three case studies are presented to illustrate the clinical usefulness of serial electrophysiologic and behavioral audiologic assessments in describing CNS function in severe head injury. There was an association among acute auditory brain stem and middle-latency evoked response findings, computed tomography of brain abnormality and neurologic status, and rate of recovery. Auditory evoked response findings 4 days after injury were also correlated with long-term outcome of diagnostic speech audiometry.

Twenty-six adult patients with CT scans were given the Wechsler Adult Intelligence Scale (WAIS) during recovery from an acute head injury. Focal lesions were observed on the initial CT scans of 24 patients. These included 13 in the right hemisphere, 8 in the left hemisphere and 3 in both hemispheres. Diffuse cerebral swelling was observed in the remaining 2 patients. Both the standard WAIS examination (11 subtests) and a shorter version described by McFie (7 subtests) were used to assess psychological impairment associated with CT documented lesions. The McFie method involved a special scoring procedure that utilized reference subtests as an index of premorbid functioning. When mean algebraic differences between Verbal and Performance subtests were used, both methods differentiated left and right-sided lesions to a highly significant degree (p less than .001). Lateralized lesions yielded significant differences on 3 individual subtests (1 Verbal and 2 Performance) with the McFie method and on 6 individual subtests (all Verbal) with the standard WAIS procedure. Wechsler's Deterioration Quotient did not discriminate between groups. It was concluded that the traditional distinction between Verbal and Performance subtests on the WAIS was valid for CT documented lesions, and the shorter McFie version was as effective as the standard WAIS in lateralizing psychological dysfunction. Acknowledgements. This research was supported by Contract NS 5-2316 and Grant NS 08803 from the National Institutes of Health. We are grateful to Drs. Thomas A. Gennarelli and Howard I. Hurtig for patient referrals and neurological evaluations.

Changes in the size and density of intracerebral hematomas were investigated by analyzing the sequential CT studies of 40 patients. Intracerebral hematomas decrease in density by an average of 0.7 EMI units per day. The dense portion of the hematoma decreases in size by an average of 0.65 mm per day. Mass effect does not decrease in proportion to the decrease in size of the dense portion of the hematoma but is delayed. The only instances of increasing mass effect occurred in patients undergoing surgical evacuation of the hematoma and in those who sustained trauma. Posthematoma residua include decreased parenchymal density, focal atrophy, and ventricular enlargement.

✓ Neuropsychological outcome within 1 year after severe head injury was examined in 42 conscious survivors and correlated with acute measurements of cerebral blood flow (CBF) and intracranial pressure (ICP). During acute coma, CBF was elevated in 23 patients, indicating hyperemia, and was reduced in the remaining 19 cases. Intracranial hypertension (ICP 20 mm Hg or greater) was present acutely in 15 patients and absent in 27. Occurrences of hyperemia and intracranial hypertension were significantly related. During chronic recovery, neuropsychological dysfunction was found in all cases. However, patients with hyperemia revealed greater impairment of overall intellectual and memory functions than did those with reduced flow, while patients with intracranial hypertension showed greater memory deficit than did those without ICP elevations. The results suggest that early pathophysiological events can influence subsequent neuropsychological outcome, and that chronic recovery is not homogeneous in young severely head-injured adults.

We followed 153 head-injured patients by computed tomography and neurologic examinations. Twenty-seven also received psychologic evaluations. Cerebral parenchymal disruption was the abnormality produced by head trauma most likely to result in a fixed neurologic or psychologic deficit. Extracerebral hematomas and diffuse cerebral swelling were associated with deficits only if focal parenchymal damage was also present. Of the lesions encountered, midline hemorrhages, reflecting a diffuse shearing injury, were associated with the highest morbidity and mortality. The sites of residual parenchymal damage were associated more frequently with deficits found on psychologic testing than with neurologically detected deficits.

A 9-year-old boy who had had painless progressive proptosis of the right eye for 18 months, initially diagnosed as fibrous dysplasia, was found to have a circumscribed mass involving the frontal bone in the roof of the orbit. Biopsy of the mass led to the diagnosis of juvenile ossifying fibroma and the tumor was removed by a craniotomy approach. One year after surgery, the child appeared to be healthy. Ossifying fibroma can sometimes be differentiated from fibrous dysplasia both clinically and by computed tomography. Ossifying fibroma usually appears between the ages of 7 and 28 years and produces slowly progressive proptosis and displacement of the globe in a direction that depends on the original site of the tumor. Fibrous dysplasia usually develops during the first decade of life and produces facial asymmetry, proptosis, and displacement of the globe. An ossifying fibroma characteristically has well-defined margins, is round or ovoid, is usually monostotic, and produces expansion of the involved bone. Fibrous dysplasia is usually sclerotic and expands the bone throughout its length rather than in a localized fashion. Its borders are poorly defined and the lesion is often polyostotic.

It is well established that ICP monitoring plays an important role in the management of patients with acute head injury. The present paper describes the relationship between ICP and several variables assumed to be correlated with intracranial hypertension; namely, neurological outcome, CT findings and cerebral blood flow (CBF).

Review of the computed tomographic findings in 286 patients with acute craniocerebral trauma revealed several types of lesions: hemorrhagic contusion, intracerebral and extracerebral hematomas, general and focal cerebral swelling, and shearing injury of the cerebral white matter. Hemorrhagic contusions are the most frequent lesion and may result in focal neurologic deficits. General cerebral swelling occurs frequently in children and necessitates prompt medical management for complete recovery. Mortality rates for intracerebral, subdural, and epidural hematomas were lower for this series than for series that preceded computed tomography. Because of the availability of computed tomography, there was an 84% reduction in arteriography, 58% reduction in surgical intervention, and a 24% reduction in skull radiography.

A high incidence of CBF abnormality has been reported in patients following acute head injury (Obrist et al. 1983). Previous observations in such patients suggested that both lateralized CT scan lesions and hemispheral CBF differences are associated with distinctive psychological impairment (Uzzell et al. 1979, 1980). The present study examines the relationship between acute CBF findings and subsequent neuropsychological function in survivors of severe head injury.

Transmission CT studies of 40 patients with intracerebral hematomas were used for an analysis of the perihematoma region. Nineteen of these patients had radionuclide studies. In the brain adjacent to an intracerebral hematoma, the patterns of pertechnetate uptake on scintillation scans and contrast enhancement on transmission CT resemble those observed in cerebral infarctions. The healing of the perihematoma region proceeds similarly to that of infarcts. The brain about the hematoma is ischemic tissue which behaves much like cerebral infarction not related to hematomas.

In summary, the presence of pain in a hip replaced by the Charnley technique is infrequent, but warrants careful clinical and roentgenographic evaluation for a serious complication.The most common complications responsible for persistent postoperative pain are loosening of the prosthetic components and deep infection.

The relationship between severity of injury [as determined by the Glasgow Coma Scale (GCS)] and the quality of survival (as determined by neuropsychological measurements and work return) were investigated in 54 conscious survivors within 16 months following head injury. While severely head injured (GCS less than or equal to 8) patients had more neuropsychological impairments in areas of intelligence, attention, memory, visuomotor speed, and motor skills than those with mild injuries (GCS greater than 8), performances after both types of injury were below normative levels in areas of learning, memory, and visuomotor speed. Unemployment increased after both severe and mild injuries, while employment status changed more frequently after severe injuries. Age had a minimal effect on neuropsychological and employment outcomes after minor head injuries (GCS greater than 13). The findings suggest that regardless of acute severity, closed head injury influences long-term quality of survival.

✓ The commonest initial computerized tomography (CT) finding in head-injured children is bilateral diffuse cerebral swelling. Cerebral blood flow and CT density studies suggest that this swelling is due to cerebral hyperemia and increased blood volume, not to edema. The clinical history, course, and outcome of 63 children with this CT pattern are reviewed. Fourteen children had a Glasgow Coma Scale score of greater than 8; all made a complete recovery and follow-up CT scans were normal. Forty-nine children had Glasgow Coma Scale scores of 8 or less. Fifteen had a history of a lucid period following the initial unconsciousness. One of these children died of delayed brain swelling, the others recovered well with minimal neurological deficit. Thirty-four children were rendered immediately and continuously unconscious. There was a high incidence of second lesions on the CT scan, 50% of this group developed intracranial hypertension and five died. All of the others were in coma for periods ranging from weeks to months. Follow-up CT scans showed an extracerebral collection with a density of cerebrospinal fluid in 27% of the patients, and ventriculomegaly with large sulci in 35%, whereas this pattern was seen only once in those with a lucid period. The difference between those with and without a lucid period is related to the degree of primary diffuse impact injury to the white matter.

There is increasing evidence that intracranial pressure is a significant determinant of outcome following acute head injury (Marshall et al. 1979, Pitts et al. 1980, Narayan et al. 1982). Although the mechanism for this is not fully understood, recent reports on the relationship between CT scan and outcome (Van Dongen et al. 1983, Toutant et al. 1984), and between ICP and CT scan (Murphy et al. 1983), suggest that brain swelling accompanied by compression of the basal cisterns plays an important role. Evidence that cerebral circulatory factors contribute to brain swelling and elevations of ICP has also been reported (Bruce et al. 1981, Obrist et al. 1984). The present paper examines the interrelationship of ICP, cerebral blood flow (CBF) and CT scan evidence of brain swelling, with special emphasis on the correlation of these variables to neuropsychological outcome.

• A total of 159 head-injured patients were classified into four groups based on two acute categories of injury severity (minor-to-moderate and severe) and the subsequent presence or absence of visual field defects (VFDs). They were assessed neuropsychologically within ten to 19 months after injury. Within both minor-to-moderate and severe injury classifications, patients with VFDs were more impaired neuropsychologically and had more frequent acute secondary intracranial complications (brain swelling, intracranial hypertension, and cerebral hyperemia) than patients without VFDs. The findings suggest that the presence of VFDs during the long-term period may be residuals of acute secondary complications indicative of increased neuropsychological deficits after head injury.