Cases reported "Brain Injuries"

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1/35. Differential pupillary constriction and awareness in the absence of striate cortex.

    The fact that the pupil constricts differentially to visual stimuli in the absence of changes in light energy makes it a valuable tool for studying normal function as well as residual capacity in hemianopic subjects. When pupillometrically effective stimuli such as equiluminant gratings or coloured patches with an abrupt onset and offset are presented to the 'blind' hemifield, a hemianopic subject with damage largely restricted to striate cortex (V1) sometimes reports being 'aware' of the transient onset/offset, although without 'seeing' as such. The question addressed here is whether the pupil still responds in the condition of blindsight in its strict sense--i.e. discriminative capacity in the absence of acknowledged awareness--when stimuli are deliberately designed to eliminate awareness. This was accomplished by making stimulus onset and offset slow and gradual. The results with a well-studied hemianope, G.Y., demonstrate that there is still a pupillary constriction to isoluminant achromatic gratings and red-coloured stimuli, although reduced in size, in the absence of acknowledged awareness.
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2/35. The late neurological, psychological, and social aspects of severe traumatic coma.

    Thirty patients who had survived a heavy head trauma and a post-traumatic coma, lasting for more than one week, were investigated 8 to 14 years after the trauma. The patients have been followed up from a social, psychological, and neurological point of view. Fifty per cent of these patients are considered to be well rehabilitated. All the investigated patients showed slight to severe reduction in mental capacity. Eighty per cent of the patients had neurological defects which were not as important with respect to social rehabilitation as was the mental capacity reduction.
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3/35. Management of the upper limb with botulinum toxin type A in children with spastic type cerebral palsy and acquired brain injury: clinical implications.

    The aim of this article is to describe our clinical experience in treating muscle imbalance in 49 children with spastic upper extremity involvement. We discuss four cohorts of children treated with botulinum toxin type A (BTX-A), each with different treatment objectives. In the first group, 27 children were treated for functional improvement and, of these, 23 had a positive effect, while four had no objective benefit. In the second group, eight children were treated for purposes of presurgical planning; of these, four were referred for surgery, three continued with serial treatment and one child did not benefit from injection. The third group comprised six children who were treated to improve posture and care: in this group, four children demonstrated clear benefit and two children lost some function subsequent to injection. Finally, a fourth group of seven children were treated after acquired brain injury (three with severe tetraplegia, four with hemiplegia). In this group, all children experienced spasticity relaxation and two children with hemiplegia also gained functional benefit. In terms of adverse events, deterioration of upper extremity function was poorly tolerated but limited to the first 1--3 weeks postinjection. Grip strength or thumb grip were diminished if too high doses were used. overall, our results with BTX-A were rewarding in children with no fixed contracture, good motor learning capacity and high motivation to train. Additionally, BTX-A treatment has proven valuable for counteracting spasticity in children with acquired brain injury. This treatment modality may not, however, be an appropriate treatment option for all children with severe upper extremity spasticity, due to the shorter duration of effect and the potential reduction in functional abilities seen in this cohort. In all cases, the selection of muscles to be treated needs careful clinical assessment. Dynamic EMG analysis should be performed whenever required to aid muscle selection, especially in children with spasticity combined with dystonia. Evaluation of M-responses suggests that for the forearm muscles, doses of BTX-A above 1.5 U/kg/muscle should not be used.
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4/35. Preserved semantic access in global amnesia and hippocampal damage.

    C.B., a right-handed 33-year-old man, presented with anterograde amnesia after acute heart block. Cognitive abilities were normal except for serious impairment of long-term episodic memory. The access to semantic information was fully preserved. Magnetic resonance showed high signal intensity and marked volume loss in the hippocampus bilaterally; the left and right parahippocampal gyrus, lateral occipito-temporal gyrus, inferior temporal gyrus, and lateral temporal cortex were normal. This case underlines that global amnesia associated with hippocampal damage does not affect semantic memory. Although the hippocampus is important in retrieving context-linked information, its role is not so crucial in retrieving semantic contents. Cortical areas surrounding the hippocampus and lateral temporal areas might guide the recall of semantic information.
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5/35. Meeting of the minds: ego reintegration after traumatic brain injury.

    Many symptoms of brain injury (e.g, difficulties with speech, intellectual functions, concentration, flatness or lability, distractibility) bear a close resemblance to inhibitions and compromise formations evident in problematic intrapsychic development. Disturbances in intrapsychic function can have an organic basis, and errors in differential diagnosis can result when therapists do not consider intrapsychic and organic damage in combination. brain-injured individuals need others who are comfortable providing auxiliary functions, particularly as an aid in managing anxiety. Understanding the operation of anxiety after brain injury can further the capacity of these individuals to attain and maintain more gratifying interpersonal relationships.
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6/35. head injury by gunshots from blank cartridges.

    BACKGROUND: Blank cartridge handguns are generally underestimated in their capacity to inflict serious and potentially life threatening injuries. The predominant reasons for these injuries are suicide or suicide attempts, followed by accidental injuries. methods: A series of 26 gas gunshots to the neurocranium is presented. The injury pattern relevant to neurosurgical practice is illustrated in a case summary of 7 selected cases and the clinical courses as well as outcomes are presented. RESULTS: The injury pattern demonstrates that the energy density of the gas jet and the high temperatures of the exploding gas volume cause extensive soft tissue injuries. In close-range shots the gas jet takes on physical properties of a projectile. In these injuries impression fractures and dislocation of bone fragments are common. CONCLUSIONS: Gas handguns, contrary to public opinion, are dangerous weapons and may inflict potentially fatal injuries to the neurocranium when fired at close range. These weapons are frequently used in criminal or careless activities predominantly by young males. Extensive CNS injuries including hematomas, subarachnoid hemorrhage, foreign body contamination, and increased intracranial pressure are frequently observed.
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7/35. Determination of cerebral water content by magnetic resonance imaging after small volume infusion of 18% hypertonic saline solution in a patient with refractory intracranial hypertension.

    Hypertonic saline solution (HSS) has been investigated in the treatment of intracranial hypertension (ICH) in a limited number of studies, usually after failure of conventional treatment. HSS, used in concentrations that vary from 3% to 23.4%, seems to be effective in reducing refractory ICH and to be devoid of adverse effects. We treated a patient with refractory ICH with a small-volume infusion of 18% HSS, and performed magnetic resonance imaging (MRI) before and after HSS infusion. MRI showed a marked reduction in cerebral water content 1 h after the infusion. To our knowledge, this is the first MRI study in a patient with brain injury to evaluate the effect of HSS on brain water content. Further studies are necessary to test HSS efficacy and to identify, through MRI or computed tomography (CT) scan imaging, a subgroup of patients with brain injury who would be best treated with HSS.
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8/35. Recombinant activated factor vii for cerebral injury-induced coagulopathy in pediatric patients. Report of three cases and review of the literature.

    brain injury remains one of the leading causes of death and disability in children. Appropriate therapy involves aggressive management of intracranial pressure (ICP) and cerebral perfusion pressure, which often requires placement of an intraparenchymal ICP monitor or intraventricular catheter. These potentially life-saving interventions require normal coagulation function; however, several factors may lead to coagulopathy in the head-injured patient. Standard therapies, which often include multiple doses of fresh frozen plasma (FFP), have a number of drawbacks when used in the pediatric population. The use of FFP requires time to type and crossmatch, thaw, and administer. It imposes a significant volume load on a child in whom cerebral edema remains a problem. Success in using recombinant activated factor vii (rFVIIa) in the hemophiliac population suggests an alternative therapy. Three patients suffered severe coagulopathy after cerebral injury. One patient received rFVIIa after repeated doses of FFP had failed to correct the coagulopathy; the other two patients received rFVIIa as the initial therapy. Treatment with rFVIIa consisted of a bolus of 90 microg/kg. Recombinant activated factor vii rapidly corrected the patients' coagulopathies, which allowed placement of intraparenchymal fiberoptic lines and intraventricular catheters to monitor ICP. The patients suffered no complication from the placement of ICP monitoring devices, as demonstrated on computerized tomography scans obtained within 24 hours after placement. brain injury-induced coagulopathy may lead to significant secondary injury and delays the invasive monitoring necessary for the aggressive management of intracranial hypertension. Fresh frozen plasma takes time to administer. may require repeated doses of significant volume for the pediatric patient, and may ultimately fail. Preliminary data indicated that rFVIIa provides a rapid and successful correction of coagulopathy in the head-injured patient.
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9/35. Cerebral perfusion pressure and cerebral tissue oxygen tension in a patient during cardiopulmonary resuscitation.

    OBJECTIVE: To report on the effects of cardiopulmonary resuscitation (CPR) instituted immediately after a cardiac arrest on cerebral perfusion pressure (CPP) and cerebral tissue oxygen tension (PbrO(2)). DESIGN: Case report. SETTING: ICU of a university hospital. PATIENT: A head-injured 17-year-old man submitted to multimodal neurological monitoring underwent sudden cardiac arrest and successful CPR. INTERVENTIONS: External chest compression, 100% oxygen ventilation, volume expansion and standard ACLS protocols. MEASUREMENTS AND RESULTS: heart rate, ECG, mean arterial blood pressure (MABP), ETCO(2), PaO(2), intracranial pressure (ICP), CPP and PbrO(2) were continuously monitored during CPR and data recorded at 15-s intervals by a dedicated personal computer. At the onset of the cardiac arrest, PbrO(2) decreased to zero. The institution of CPR resulted in a progressive increase of MABP, CPP and PbrO(2). Assuming, on the basis of previous experimental and clinical reports, 8 mmHg PbrO(2) as a possible ischaemic/hypoxic threshold value, during the first 6.5 min of CPR, PbrO(2) values were below this threshold (range 0-7 mmHg) and CPP values were <25 mmHg for 81.5% of the time. In the following 5.5 min, more efficient CPR generated CPP values >25 mmHg for 77.3% of the time. These values were associated with a PbrO(2) >8 mmHg (range 8-28 mmHg) at all times. CONCLUSIONS: In the clinical setting of a witnessed cardiac arrest, immediate institution of CPR can be effective in generating PbrO(2) values above a supposed ischaemic/hypoxic threshold when CPP is >25 mmHg. PbrO(2) monitoring by the Licox system is sensitive and reliable, even at low values, and can be suitable for evaluating cerebral oxygenation during experimental CPR.
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10/35. Effectiveness of the ISAAC cognitive prosthetic system for improving rehabilitation outcomes with neurofunctional impairment.

    Cognitive rehabilitation has the capacity to empower persons with brain-injuries and help them achieve heightened functional, personal, and social interactions within their environments. Interventions aimed at compensation for deficits and adaptation to cognitive disability can be aided through the use of assistive technology devices (ATD's). ATDs allow for their users to experience greater levels of independence, as well as social and vocational participation, which leads to a higher quality of life. The ISAAC system is a small, individualized, wearable cognitive prosthetic assistive technology system. Being fully individualized and very easy to use makes this system adaptable to, and appropriate for, patients with a wide variety of cognitive disabilities ranging from individuals with developmental disabilities to high functioning survivors of brain injury. The current article will discuss two cases that illustrate the effectiveness of the ISAAC system in assisting patients with generalization of rehabilitation to their home environments. Both patients incurred significant cognitive impairment, for which they were able to successfully compensate with the assistance of their ISAAC systems. These two case studies are typical examples of the functional independence that can be achieved through the use of the ISAAC system. When patients are properly selected for use of this system, appropriate content is authored, and sufficient training on the system is provided, the ISAAC system can prove very effective at improving patients' functional independence.
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