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edema in damaged areas of the brain The control of high blood pressure must be balanced against the risk of reducing cerebral perfusion pressure and the observation that even a brief period of mild hypotension may provoke a cycle of cerebral vasodilation, increased cerebral blood volume, and elevated ICP in the form of plateau waves (Rosner and Becker) Observations such as these emphasize the need for immediate and vigorous management of hypotension in severely head-injured patients Since most therapies for elevated ICP dehydrate the patient or reduce cardiac lling pressures, thereby leading to hypotension, a middle course, of avoiding both severe hypertension and any degree of hypotension, seems the best compromise In lowering high levels of blood pressure, diuretics, beta-adrenergic blocking agents, or angiotensin converting enzyme inhibitors should be used, rather than agents that may dilate the cerebral vasculature (nitroglycerin and nitroprusside, hydralazine, and some of the calcium channel blockers) Hypotension should be corrected by vasopressor agents such as neosynephrine The precise level of blood pressure that requires treatment must be judged in the context of the ICP and the presence of plateau waves (the goal being to maintain normal cerebral perfusion) as well as the patient s previous blood pressure level; evidence of organ failure, such as cardiac or renal ischemia, must also be taken into account General Medical Measures If coma persists for more than 48 h, a nasogastric tube should be passed and uids and nutrition given by this route Agents that reduce gastric acid production or the equivalent, antacids by stomach tube to keep gastric acidity at a pH above 35 are of value in preventing gastric hemorrhage The prophylactic use of anticonvulsant drugs, as discussed earlier, under Posttraumatic Epilepsy, has recently been favored, but there is no evidence that delayed epileptic seizures are reduced (see Chand and Lowenstein) Only if there has been a seizure are anticonvulsants given Restlessness is controlled by diazepam or a similar sedative, but only if careful nursing fails to quiet the patient and provide sleep for a few hours at a time Haloperidol is usually avoided in the acute stage Fever is counteracted by antipyretics such as acetaminophen, and, if necessary, by a cooling blanket The use of morphine or bromocriptine to quiet episodes of vigorous extensor posturing and accompanying adrenergic activity has already been mentioned Surgical Measures The need for surgical intervention during the acute posttraumatic period is decided by two factors: the clinical status of the patient and CT scanning The presence of a subdural or epidural clot that is causing a shift of central brain structures calls for its immediate evacuation The approach to subdural hematomas has been discussed earlier in this chapter Should the elevated ICP not respond to this procedure or to the standard osmotic agents and other medical measures outlined above, or should the condition of the patient and vital signs then begin to deteriorate (pulse rising, temperature rising or falling below normal, state of consciousness worsening, hemiplegia more obvious, plantar re exes more clearly extensor), a renewed search must be undertaken for a late-occurring cerebral mass Usually in these clinical circumstances, CT scanning will disclose a new or enlarged epidural, subdural, or intracerebral hematoma, marked cerebral edema, and a lateral shift of central cerebral structures If death or severe disability is to be avoided, operation in these cases must be undertaken before the advanced signs of brainstem compression de-.

cerebrate or decorticate posturing, hypertension, bradycardia have appeared The use of decompressive craniectomy in patients with progressive and intractable traumatic brain swelling has been a subject of renewed interest in recent years, after having been practically abandoned several decades ago Guerra and colleagues have reported on 57 such patients, mostly young adults, who underwent wide frontotemporal craniectomy, unilateral in 31 and bilateral in 26 Of these, 11 patients died, 5 remained in a persistent vegetative state, and 6 survived in a severely damaged condition; however, 33 patients (58 percent) attained surprisingly good states of rehabilitation These authors were of the opinion that these results represented a signi cant improvement over the expected outcome in this particular group of patients Similar results in children have been reported by Polin et al The few cases with which we have been involved, mostly children operated late, have not been as encouraging, but the procedure deserves further evaluation, especially in younger patients The treatment of other problems attendant on protracted coma has been outlined in Chap 17 Each patient presents unique problems that must be dealt with individually

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In respect to severe head injury, as has been intimated, the outcome is particularly discouraging Some aspects of prognosis have been mentioned earlier but the following general comments serve to frame the problem In the survey of the large European Brain Injury Consortium, comprising 10,005 adult patients, the injury proved fatal in 31 percent; 3 percent were left in a persistent vegetative state, and 16 percent remained severely disabled neurologically (Murray et al) Data from the extensively analyzed Traumatic Coma Data Bank are comparable (Marshall et al) The signs of focal brain disease, whether due to closed head injuries or to open and penetrating ones, tend always to ameliorate as the months pass A hemiplegia is often reduced to a minimal hemiparesis or to an ineptitude of voluntary motor function with exaggerated re exes

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and an equivocal Babinski sign on that side, and an aphasia is gradually transformed into a stuttering or hesitant paraphasia or dysnomia that is not disabling except to a professional person, speaker, or writer Many of the signs of brainstem disease (cranial nerve dysfunction and ataxia) improve also, usually within the rst 6 months after injury (Jennett and Bond) and often to a surprising extent Most patients who had been in coma for many hours or days ie, those with severe brain injuries are left with memory impairment and other cognitive defects and with personality changes These may be the only lasting sequelae According to Jennett and Bond, these mental and personality changes are a greater handicap than focal neurologic ones as far as social adjustment is concerned In open head wounds and penetrating brain injuries, Grafman and coworkers found that the magnitude of tissue loss and location of the lesion were the main factors affecting the outcome The prognosis of head injury is in uenced by several other factors The age of the patient is the most important of these (Vollmer et al) Increasing age reduces the chances of survival and of good recovery Older patients often remain disabled, especially when compensation is involved Young and middle-aged ones do better, particularly if they are not entitled to compensation Russell has pointed out that the severity of the injury as measured by the duration of traumatic amnesia is a useful prognostic index Of patients with a period of amnesia lasting less than 1 h, 95 percent were back at work within 2 months; if the amnesia lasted longer than 24 h, only 80 percent had returned to work within 6 months However, about 60 percent of the patients in his large series still had symptoms at the end of 2 months, and 40 percent at the end of 18 months Of the most severely injured (those comatose for several days), many remained permanently disabled However, the degree of recovery was often better than one had expected; the motor impairment, aphasia, and dementia tended to lessen and sometimes cleared Improvement could continue over a period of 3 or more years Children seemed to recover more completely than adults.