Neurosurgery & Trauma

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

SAN FRANCISCO — The largest series of head injury patients to undergo magnetic resonance imaging found brain stem injuries in 60% of 200 patients, a much higher rate than the 10% usually quoted in the literature, Dr. Raimund P. Firsching reported at the annual meeting of the American Association of Neurological Surgeons.

Fewer than 1 in 10 brain stem lesions were visible on CT scans, he said.

Investigators performed CT and MRI scans on patients within a week of head injury; all patients were in a coma for at least 1 day.

Functional and mortality outcomes 3 months after injury were associated with the location of brain injury on MRI, with much worse prognoses in patients who had brain stem lesions, said Dr. Firsching, of the department of neurosurgery at Otto-von-Guericke University, Magdeburg, Germany, who conducted the study with Dr. Dieter Woischneck, also of the university.

The results challenge the commonly held notion that when CT shows no lesions after brain trauma, a patient's failure to improve must be a result of diffuse brain injury, Dr. Firsching said.

Among patients who emerged from coma after 1 day, 63% had brain stem lesions seen on MRI.

The longer the coma lasted, the greater the likelihood of brain stem lesion: Of patients who were in a coma for 1 week, 96% had brain stem lesions. “This is really in sharp contrast to the literature,” he noted.

The imaging could not differentiate between primary and secondary lesions, he acknowledged.

Commenting on the study at the meeting, Dr. M. Ross Bullock said that it was limited by not identifying postherniation changes in the brain, by not reporting how many patients had lesions removed, and by not discussing the implications of high intracranial pressure with the MRI findings.

“If these data represent simply a very high, unusual incidence of herniation, that's not a major contribution to our knowledge base,” said Dr. Bullock, the Reynolds Professor of neurosurgery at Virginia Commonwealth University, Richmond, Va.

At his institution, MRIs on 13 patients with trauma found brain stem lesions in 10%, he noted.

Among all patients in Dr. Firsching's study, 37% had supratentorial lesions confined to the hemispheres or the corpus callosum; two-thirds of this group had a good outcome, and 10% died, Dr. Firsching reported. A lesion in a unilateral region of the brain stem, seen in 20% of patients, was associated with a slight or moderate functional handicap after 3 months, and 21% of these patients died. Severe disability was likely in the 22% of patients with bilateral mesencephalic lesions, and 21% died. Among the 21% of patients with a bilateral pontine lesion, 92% died.

Lesions on the corpus callosum did not predict the likelihood of death or the length of coma, he added. Pontine and midbrain lesions, which CT failed to detect, are most important for prognosis, he emphasized.

In nearly 10 years of doing MRIs on brain trauma patients, “we have yet to see a patient who was in a vegetative state who did not exhibit a bilateral pontine lesion,” Dr. Firsching said.

The investigators began the series of MRIs on head trauma patients after a man in a bus accident failed to emerge from his coma. The patient's brother, a neuroradiologist, insisted on getting an MRI, which showed lesions that were invisible on CT. MRI is indicated in the evaluation of some head trauma patients who don't improve over time, according to Dr. Bullock.

CT shows large extradural hematoma (left). MRI of midline shows traumatic lesion; tissue extends into brain stem (right). Courtersy Dr. Raimund P. Firsching

Although nerve transplantations are rarely performed, they can provide an alternative to amputation, and some surgeons say they should be considered for seriously injured patients.

Surgeons interviewed for this article identified a total of nine neurosurgeons and plastic surgeons, including themselves, who have transplanted nerves from living donors for more than 10 years.

The surgeons believe that thousands of patients—including soldiers returning from Iraq—could benefit from transplantations and similar procedures. Soldiers who suffer blunt injuries to an isolated spot of nerve would be especially good candidates, said Dr. Andrew Elkwood in an interview.

Dr. Susan Mackinnon, a plastic surgeon at Washington University in St. Louis, performed the first nerve transplantation from a live donor in 1989 in Canada. Transplantation is used as a last resort if patients do not have enough of their own nerve tissue for a graft, she said.

Grafts of patients' own nerve tissues have been around for years, said Dr. Elkwood, a plastic surgeon who practices in New Jersey.

Both surgeons prefer live donors over cadavers for transplantations because family members usually are willing to donate nerve tissue immediately and such tissue is less likely to be rejected than cadaver tissue. It can take several months to find an appropriate cadaver, they added.

The ideal time for a transplantation is 3 months after injury, according to Dr. Elkwood.

In November, Dr. Allan Belzberg, a neurosurgeon at Johns Hopkins University, performed his first allograft transplantation of nerves from a 40-year-old mother to her 19-year-old son, to restore the use of his hand 1 year after an automobile accident left him with left leg amputation and 14-cm gaps in the median and ulnar nerves of the left arm going to the hand.

Dr. Belzberg opted against an autologous graft of expendable leg nerves because the patient had already lost one leg and the other had been broken in seven places. Nor did he want to remove nerves from the patient's one good arm.

Dr. Belzberg harvested nerves from the mother's legs and arms.

Within 3 months, Dr. Belzberg should know if the patient's nerves have regenerated. If all goes well, he will regain motion in his fingers within 8 months and, within 2 years, bend his elbow, grasp with his fingers, and feel protective sensations such as pain, cold, and heat, Dr. Belzberg said. He estimated the chances of achieving these outcomes as 50%–75%.

The patient will take the immunosuppression drug tacrolimus (FK 506) for about 2 years. One side effect of the drug is nerve growth, but Dr. Belzberg said he and a team of other doctors believe the drug is unlikely to spur tumor formation.

Dr. Mackinnon and other surgeons are now using another technique, nerve transfer, to treat patients in whom part of the brachial plexus has been torn. Nerve transfer consists of sacrificing the function of expendable portions of a patient's healthy nerves to revive function in a seriously injured, more crucial nerve.

Bundles of a healthy nerve near the motor end plate of the damaged muscle are teased apart and redirected to revive function in the recipient nerve and muscle. No grafting is necessary.

The technique changes the nerve injury from a proximal injury to a distal one, so nerves—which regenerate only about an inch a month—have less distance to grow, Dr. Mackinnon said.

For example, an injury to the ulnar nerve in the upper arm can require 2 years of recovery after grafting. But “stealing” nerve fibers from the pronator quadratus would require only a few months of recovery, Dr. Mackinnon said.

“There's a strong need for these procedures [transplantations and transfers],” Dr. Elkwood said, adding that too many physicians are unaware they are being done successfully. “We need massive education [about these procedures]. They need to become more mainstream in the lay and medical communities,” he said.

Although nerve transplantations are rarely performed, they can provide an alternative to amputation, and some surgeons say they should be considered for seriously injured patients.

Surgeons interviewed for this article identified a total of nine neurosurgeons and plastic surgeons, including themselves, who have transplanted nerves from living donors for more than 10 years.

The surgeons believe that thousands of patients—including soldiers returning from Iraq—could benefit from transplantations and similar procedures. Soldiers who suffer blunt injuries to an isolated spot of nerve would be especially good candidates, said Dr. Andrew Elkwood in an interview.

Dr. Susan Mackinnon, a plastic surgeon at Washington University in St. Louis, performed the first nerve transplantation from a live donor in 1989 in Canada. Transplantation is used as a last resort if patients do not have enough of their own nerve tissue for a graft, she said.

Grafts of patients' own nerve tissues have been around for years, said Dr. Elkwood, a plastic surgeon who practices in New Jersey.

Both surgeons prefer live donors over cadavers for transplantations because family members usually are willing to donate nerve tissue immediately and such tissue is less likely to be rejected than cadaver tissue. It can take several months to find an appropriate cadaver, they added.

The ideal time for a transplantation is 3 months after injury, according to Dr. Elkwood.

In November, Dr. Allan Belzberg, a neurosurgeon at Johns Hopkins University, performed his first allograft transplantation of nerves from a 40-year-old mother to her 19-year-old son, to restore the use of his hand 1 year after an automobile accident left him with left leg amputation and 14-cm gaps in the median and ulnar nerves of the left arm going to the hand.

Dr. Belzberg opted against an autologous graft of expendable leg nerves because the patient had already lost one leg and the other had been broken in seven places. Nor did he want to remove nerves from the patient's one good arm.

Dr. Belzberg harvested nerves from the mother's legs and arms.

Within 3 months, Dr. Belzberg should know if the patient's nerves have regenerated. If all goes well, he will regain motion in his fingers within 8 months and, within 2 years, bend his elbow, grasp with his fingers, and feel protective sensations such as pain, cold, and heat, Dr. Belzberg said. He estimated the chances of achieving these outcomes as 50%–75%.

The patient will take the immunosuppression drug tacrolimus (FK 506) for about 2 years. One side effect of the drug is nerve growth, but Dr. Belzberg said he and a team of other doctors believe the drug is unlikely to spur tumor formation.

Dr. Mackinnon and other surgeons are now using another technique, nerve transfer, to treat patients in whom part of the brachial plexus has been torn. Nerve transfer consists of sacrificing the function of expendable portions of a patient's healthy nerves to revive function in a seriously injured, more crucial nerve.

Bundles of a healthy nerve near the motor end plate of the damaged muscle are teased apart and redirected to revive function in the recipient nerve and muscle. No grafting is necessary.

The technique changes the nerve injury from a proximal injury to a distal one, so nerves—which regenerate only about an inch a month—have less distance to grow, Dr. Mackinnon said.

For example, an injury to the ulnar nerve in the upper arm can require 2 years of recovery after grafting. But “stealing” nerve fibers from the pronator quadratus would require only a few months of recovery, Dr. Mackinnon said.

“There's a strong need for these procedures [transplantations and transfers],” Dr. Elkwood said, adding that too many physicians are unaware they are being done successfully. “We need massive education [about these procedures]. They need to become more mainstream in the lay and medical communities,” he said.

Although nerve transplantations are rarely performed, they can provide an alternative to amputation, and some surgeons say they should be considered for seriously injured patients.

Surgeons interviewed for this article identified a total of nine neurosurgeons and plastic surgeons, including themselves, who have transplanted nerves from living donors for more than 10 years.

The surgeons believe that thousands of patients—including soldiers returning from Iraq—could benefit from transplantations and similar procedures. Soldiers who suffer blunt injuries to an isolated spot of nerve would be especially good candidates, said Dr. Andrew Elkwood in an interview.

Dr. Susan Mackinnon, a plastic surgeon at Washington University in St. Louis, performed the first nerve transplantation from a live donor in 1989 in Canada. Transplantation is used as a last resort if patients do not have enough of their own nerve tissue for a graft, she said.

Grafts of patients' own nerve tissues have been around for years, said Dr. Elkwood, a plastic surgeon who practices in New Jersey.

Both surgeons prefer live donors over cadavers for transplantations because family members usually are willing to donate nerve tissue immediately and such tissue is less likely to be rejected than cadaver tissue. It can take several months to find an appropriate cadaver, they added.

The ideal time for a transplantation is 3 months after injury, according to Dr. Elkwood.

In November, Dr. Allan Belzberg, a neurosurgeon at Johns Hopkins University, performed his first allograft transplantation of nerves from a 40-year-old mother to her 19-year-old son, to restore the use of his hand 1 year after an automobile accident left him with left leg amputation and 14-cm gaps in the median and ulnar nerves of the left arm going to the hand.

Dr. Belzberg opted against an autologous graft of expendable leg nerves because the patient had already lost one leg and the other had been broken in seven places. Nor did he want to remove nerves from the patient's one good arm.

Dr. Belzberg harvested nerves from the mother's legs and arms.

Within 3 months, Dr. Belzberg should know if the patient's nerves have regenerated. If all goes well, he will regain motion in his fingers within 8 months and, within 2 years, bend his elbow, grasp with his fingers, and feel protective sensations such as pain, cold, and heat, Dr. Belzberg said. He estimated the chances of achieving these outcomes as 50%–75%.

The patient will take the immunosuppression drug tacrolimus (FK 506) for about 2 years. One side effect of the drug is nerve growth, but Dr. Belzberg said he and a team of other doctors believe the drug is unlikely to spur tumor formation.

Dr. Mackinnon and other surgeons are now using another technique, nerve transfer, to treat patients in whom part of the brachial plexus has been torn. Nerve transfer consists of sacrificing the function of expendable portions of a patient's healthy nerves to revive function in a seriously injured, more crucial nerve.

Bundles of a healthy nerve near the motor end plate of the damaged muscle are teased apart and redirected to revive function in the recipient nerve and muscle. No grafting is necessary.

The technique changes the nerve injury from a proximal injury to a distal one, so nerves—which regenerate only about an inch a month—have less distance to grow, Dr. Mackinnon said.

For example, an injury to the ulnar nerve in the upper arm can require 2 years of recovery after grafting. But “stealing” nerve fibers from the pronator quadratus would require only a few months of recovery, Dr. Mackinnon said.

“There's a strong need for these procedures [transplantations and transfers],” Dr. Elkwood said, adding that too many physicians are unaware they are being done successfully. “We need massive education [about these procedures]. They need to become more mainstream in the lay and medical communities,” he said.

ATLANTA — Computed tomographic angiography with a 16-channel detector can be used to accurately screen patients for blunt cervical vascular and cerebrovascular injuries, according to two studies presented at the annual meeting of the American Association for the Surgery of Trauma.

“Though ours was a relatively small study population and future studies are needed to focus on the accuracy of grading by CTA, this technology should be considered the screening standard for patients at risk of blunt cervical vascular injury,” said chief author Alexander L. Eastman, M.D., of the University of Texas Southwestern Medical Center in Dallas. “The severe and unforgiving nature of an undiagnosed blunt cervical vascular injury presents a real problem. Given the large differences in treated and untreated stroke rates, the principle of screening and early detection is vital. Despite this, the definition of an ideal screening test remains controversial, [though] catheter arteriography remains the 'gold standard.'”

In previous head-to-head studies using less powerful scanners, CTA failed to match the performances of catheter arteriography (CA). When a new 16-channel machine arrived at Parkland Hospital, the Dallas researchers decided to put it to the test.

Data from all patients presenting to their level I trauma center at risk for blunt cervical vascular injury were collected prospectively. During an 8-month period, each patient was evaluated with CTA and the findings confirmed with standard CA of the head, neck, and aortic arch.

Of more than 3,000 trauma admissions during 8 months, 148 patients were deemed at risk for blunt cervical vascular injury. A total of 135 patients received both CTA and CA, and 13 received CTA only, due primarily to patient rejection of CA and discharge prior to CA. Among 41 patients, 43 blunt cervical vascular injuries were identified, yielding an overall incidence of 1.4% and an incidence within the screened population of more than 30%. Results of the two procedures were concordant in 42 of 43 cases with blunt cervical vascular injuries.

The remaining patients had normal CTAs confirmed by a normal CA, the investigators wrote.

The overall incidence of carotid artery injury (CAI) was 0.6% and vertebral artery injury (VAI) was 96%. Of the VAIs, 96% were associated with at least one cervical spine fracture. In the patients who underwent both CTA and CA, the detection sensitivity of CTA was 100% for CAI and 96% for VAI.

The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CTA for blunt cervical vascular injury were 97.1%, 100%, 100%, 98.9%, and 99.3%, respectively, they said.

An additional enhancement offered by CTA is the ability to subtract other anatomic structures and focus on the vascular system exclusively, Dr. Eastman said. Vertebral artery injuries also are impressive when viewed at the CT workstation, he added.

When patients with negative CTA who did not have an angiogram were followed up at 3–12 months, none were found to have an injury or neurologic sequelae.

Following Dr. Eastman's presentation, discussant David A. Spain, M.D., agreed that 16-slice CTA is ready for prime time. However, “Is it ready for non-prime time?” asked Dr. Spain, who is with the Stanford University Medical Center, Stanford, Calif. “Who reads these studies at 2 a.m.? Three-dimensional reconstructions are very important to accurate interpretations, and if no one is available to read the exam, how long before you have a definitive answer as to whether these patients have an injury?” he added.

“I think obviously there's going to be some house staff reading at first,” replied Dr. Eastman. “We're lucky at our institution that our neuroradiologists are exquisitely helpful … so you get a reading almost immediately.”

CTA vs. ART

The second study, conducted at Rhode Island Hospital and Brown Medical School in Providence, compared 16-slice CTA with 4-vessel cerebral arteriography (ART) in screening for blunt cerebrovascular injuries.

Screening detects many asymptomatic cerebrovascular injuries. “However, it has not been proven to prevent strokes, and thus many centers have been reluctant to implement screening protocols,” they wrote. “It is particularly difficult to justify because ART, the gold-standard diagnostic test, is invasive and resource intensive.”

“We developed our screening protocol using arteriography for symptomatic patients because … we need a gold standard test when a patient is having symptoms or signs consistent with an injury,” said lead author Walter L. Biffl, M.D. The investigators settled on 16-slice CTA for patients with high-risk mechanisms and injury patterns. To further capture any group that may be at risk, they enlarged the study group to include any patient with cranial or cervical trauma who was undergoing a CT scan.

The protocol called for CTA in all trauma patients with cranial or cervical trauma undergoing CT scanning. Any abnormality was further investigated with ART, and patients were followed for neurologic changes. The investigators reviewed records to determine if clinical injuries were missed by CTA, and then compared ART and CTA images.

Between June 2004 and February 2005, the team did 225 CTAs. A total of 17 patients (7.5%) were diagnosed with blunt cerebrovascular injuries, including 11 carotid and 6 vertebral injuries. CTA did not miss any clinically important blunt cerebrovascular injury, the researchers said.

“Importantly, nobody during the study period who had had a normal CTA developed signs or symptoms of a vascular injury, and that was what we set out to explore,” Dr. Biffl said. “The disconcerting thing in this study is that two patients who didn't meet the screening criteria presented with symptoms related to a vascular injury.”

One of those patients was an elderly man who had been in a minor auto accident. He was evaluated and sent home from the emergency department, but returned with persistent headache and Horner Syndrome. He was found to have dissection of the carotid artery. The other patient was a young woman who had fractures of the femur and clavicle who, because she didn't have cranial or cervical trauma, didn't undergo a CTA. She woke up the next day in the orthopedic service with a stroke.

“We've concluded from this study that CTA is a reliable, noninvasive screening test for clinically significant blunt cervical vascular injuries,” Dr. Biffl said. “We need multicenter prospective trials to clarify the risk factors and to assess the accuracy of noninvasive screening tests and to evaluate the efficacy of treatment strategies,” he added.

ATLANTA — Computed tomographic angiography with a 16-channel detector can be used to accurately screen patients for blunt cervical vascular and cerebrovascular injuries, according to two studies presented at the annual meeting of the American Association for the Surgery of Trauma.

“Though ours was a relatively small study population and future studies are needed to focus on the accuracy of grading by CTA, this technology should be considered the screening standard for patients at risk of blunt cervical vascular injury,” said chief author Alexander L. Eastman, M.D., of the University of Texas Southwestern Medical Center in Dallas. “The severe and unforgiving nature of an undiagnosed blunt cervical vascular injury presents a real problem. Given the large differences in treated and untreated stroke rates, the principle of screening and early detection is vital. Despite this, the definition of an ideal screening test remains controversial, [though] catheter arteriography remains the 'gold standard.'”

In previous head-to-head studies using less powerful scanners, CTA failed to match the performances of catheter arteriography (CA). When a new 16-channel machine arrived at Parkland Hospital, the Dallas researchers decided to put it to the test.

Data from all patients presenting to their level I trauma center at risk for blunt cervical vascular injury were collected prospectively. During an 8-month period, each patient was evaluated with CTA and the findings confirmed with standard CA of the head, neck, and aortic arch.

Of more than 3,000 trauma admissions during 8 months, 148 patients were deemed at risk for blunt cervical vascular injury. A total of 135 patients received both CTA and CA, and 13 received CTA only, due primarily to patient rejection of CA and discharge prior to CA. Among 41 patients, 43 blunt cervical vascular injuries were identified, yielding an overall incidence of 1.4% and an incidence within the screened population of more than 30%. Results of the two procedures were concordant in 42 of 43 cases with blunt cervical vascular injuries.

The remaining patients had normal CTAs confirmed by a normal CA, the investigators wrote.

The overall incidence of carotid artery injury (CAI) was 0.6% and vertebral artery injury (VAI) was 96%. Of the VAIs, 96% were associated with at least one cervical spine fracture. In the patients who underwent both CTA and CA, the detection sensitivity of CTA was 100% for CAI and 96% for VAI.

The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CTA for blunt cervical vascular injury were 97.1%, 100%, 100%, 98.9%, and 99.3%, respectively, they said.

An additional enhancement offered by CTA is the ability to subtract other anatomic structures and focus on the vascular system exclusively, Dr. Eastman said. Vertebral artery injuries also are impressive when viewed at the CT workstation, he added.

When patients with negative CTA who did not have an angiogram were followed up at 3–12 months, none were found to have an injury or neurologic sequelae.

Following Dr. Eastman's presentation, discussant David A. Spain, M.D., agreed that 16-slice CTA is ready for prime time. However, “Is it ready for non-prime time?” asked Dr. Spain, who is with the Stanford University Medical Center, Stanford, Calif. “Who reads these studies at 2 a.m.? Three-dimensional reconstructions are very important to accurate interpretations, and if no one is available to read the exam, how long before you have a definitive answer as to whether these patients have an injury?” he added.

“I think obviously there's going to be some house staff reading at first,” replied Dr. Eastman. “We're lucky at our institution that our neuroradiologists are exquisitely helpful … so you get a reading almost immediately.”

CTA vs. ART

The second study, conducted at Rhode Island Hospital and Brown Medical School in Providence, compared 16-slice CTA with 4-vessel cerebral arteriography (ART) in screening for blunt cerebrovascular injuries.

Screening detects many asymptomatic cerebrovascular injuries. “However, it has not been proven to prevent strokes, and thus many centers have been reluctant to implement screening protocols,” they wrote. “It is particularly difficult to justify because ART, the gold-standard diagnostic test, is invasive and resource intensive.”

“We developed our screening protocol using arteriography for symptomatic patients because … we need a gold standard test when a patient is having symptoms or signs consistent with an injury,” said lead author Walter L. Biffl, M.D. The investigators settled on 16-slice CTA for patients with high-risk mechanisms and injury patterns. To further capture any group that may be at risk, they enlarged the study group to include any patient with cranial or cervical trauma who was undergoing a CT scan.

The protocol called for CTA in all trauma patients with cranial or cervical trauma undergoing CT scanning. Any abnormality was further investigated with ART, and patients were followed for neurologic changes. The investigators reviewed records to determine if clinical injuries were missed by CTA, and then compared ART and CTA images.

Between June 2004 and February 2005, the team did 225 CTAs. A total of 17 patients (7.5%) were diagnosed with blunt cerebrovascular injuries, including 11 carotid and 6 vertebral injuries. CTA did not miss any clinically important blunt cerebrovascular injury, the researchers said.

“Importantly, nobody during the study period who had had a normal CTA developed signs or symptoms of a vascular injury, and that was what we set out to explore,” Dr. Biffl said. “The disconcerting thing in this study is that two patients who didn't meet the screening criteria presented with symptoms related to a vascular injury.”

One of those patients was an elderly man who had been in a minor auto accident. He was evaluated and sent home from the emergency department, but returned with persistent headache and Horner Syndrome. He was found to have dissection of the carotid artery. The other patient was a young woman who had fractures of the femur and clavicle who, because she didn't have cranial or cervical trauma, didn't undergo a CTA. She woke up the next day in the orthopedic service with a stroke.

“We've concluded from this study that CTA is a reliable, noninvasive screening test for clinically significant blunt cervical vascular injuries,” Dr. Biffl said. “We need multicenter prospective trials to clarify the risk factors and to assess the accuracy of noninvasive screening tests and to evaluate the efficacy of treatment strategies,” he added.

ATLANTA — Computed tomographic angiography with a 16-channel detector can be used to accurately screen patients for blunt cervical vascular and cerebrovascular injuries, according to two studies presented at the annual meeting of the American Association for the Surgery of Trauma.

“Though ours was a relatively small study population and future studies are needed to focus on the accuracy of grading by CTA, this technology should be considered the screening standard for patients at risk of blunt cervical vascular injury,” said chief author Alexander L. Eastman, M.D., of the University of Texas Southwestern Medical Center in Dallas. “The severe and unforgiving nature of an undiagnosed blunt cervical vascular injury presents a real problem. Given the large differences in treated and untreated stroke rates, the principle of screening and early detection is vital. Despite this, the definition of an ideal screening test remains controversial, [though] catheter arteriography remains the 'gold standard.'”

In previous head-to-head studies using less powerful scanners, CTA failed to match the performances of catheter arteriography (CA). When a new 16-channel machine arrived at Parkland Hospital, the Dallas researchers decided to put it to the test.

Data from all patients presenting to their level I trauma center at risk for blunt cervical vascular injury were collected prospectively. During an 8-month period, each patient was evaluated with CTA and the findings confirmed with standard CA of the head, neck, and aortic arch.

Of more than 3,000 trauma admissions during 8 months, 148 patients were deemed at risk for blunt cervical vascular injury. A total of 135 patients received both CTA and CA, and 13 received CTA only, due primarily to patient rejection of CA and discharge prior to CA. Among 41 patients, 43 blunt cervical vascular injuries were identified, yielding an overall incidence of 1.4% and an incidence within the screened population of more than 30%. Results of the two procedures were concordant in 42 of 43 cases with blunt cervical vascular injuries.

The remaining patients had normal CTAs confirmed by a normal CA, the investigators wrote.

The overall incidence of carotid artery injury (CAI) was 0.6% and vertebral artery injury (VAI) was 96%. Of the VAIs, 96% were associated with at least one cervical spine fracture. In the patients who underwent both CTA and CA, the detection sensitivity of CTA was 100% for CAI and 96% for VAI.

The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CTA for blunt cervical vascular injury were 97.1%, 100%, 100%, 98.9%, and 99.3%, respectively, they said.

An additional enhancement offered by CTA is the ability to subtract other anatomic structures and focus on the vascular system exclusively, Dr. Eastman said. Vertebral artery injuries also are impressive when viewed at the CT workstation, he added.

When patients with negative CTA who did not have an angiogram were followed up at 3–12 months, none were found to have an injury or neurologic sequelae.

Following Dr. Eastman's presentation, discussant David A. Spain, M.D., agreed that 16-slice CTA is ready for prime time. However, “Is it ready for non-prime time?” asked Dr. Spain, who is with the Stanford University Medical Center, Stanford, Calif. “Who reads these studies at 2 a.m.? Three-dimensional reconstructions are very important to accurate interpretations, and if no one is available to read the exam, how long before you have a definitive answer as to whether these patients have an injury?” he added.

“I think obviously there's going to be some house staff reading at first,” replied Dr. Eastman. “We're lucky at our institution that our neuroradiologists are exquisitely helpful … so you get a reading almost immediately.”

CTA vs. ART

The second study, conducted at Rhode Island Hospital and Brown Medical School in Providence, compared 16-slice CTA with 4-vessel cerebral arteriography (ART) in screening for blunt cerebrovascular injuries.

Screening detects many asymptomatic cerebrovascular injuries. “However, it has not been proven to prevent strokes, and thus many centers have been reluctant to implement screening protocols,” they wrote. “It is particularly difficult to justify because ART, the gold-standard diagnostic test, is invasive and resource intensive.”

“We developed our screening protocol using arteriography for symptomatic patients because … we need a gold standard test when a patient is having symptoms or signs consistent with an injury,” said lead author Walter L. Biffl, M.D. The investigators settled on 16-slice CTA for patients with high-risk mechanisms and injury patterns. To further capture any group that may be at risk, they enlarged the study group to include any patient with cranial or cervical trauma who was undergoing a CT scan.

The protocol called for CTA in all trauma patients with cranial or cervical trauma undergoing CT scanning. Any abnormality was further investigated with ART, and patients were followed for neurologic changes. The investigators reviewed records to determine if clinical injuries were missed by CTA, and then compared ART and CTA images.

Between June 2004 and February 2005, the team did 225 CTAs. A total of 17 patients (7.5%) were diagnosed with blunt cerebrovascular injuries, including 11 carotid and 6 vertebral injuries. CTA did not miss any clinically important blunt cerebrovascular injury, the researchers said.

“Importantly, nobody during the study period who had had a normal CTA developed signs or symptoms of a vascular injury, and that was what we set out to explore,” Dr. Biffl said. “The disconcerting thing in this study is that two patients who didn't meet the screening criteria presented with symptoms related to a vascular injury.”

One of those patients was an elderly man who had been in a minor auto accident. He was evaluated and sent home from the emergency department, but returned with persistent headache and Horner Syndrome. He was found to have dissection of the carotid artery. The other patient was a young woman who had fractures of the femur and clavicle who, because she didn't have cranial or cervical trauma, didn't undergo a CTA. She woke up the next day in the orthopedic service with a stroke.

“We've concluded from this study that CTA is a reliable, noninvasive screening test for clinically significant blunt cervical vascular injuries,” Dr. Biffl said. “We need multicenter prospective trials to clarify the risk factors and to assess the accuracy of noninvasive screening tests and to evaluate the efficacy of treatment strategies,” he added.

SAN DIEGO — Patients with chronic spinal cord injury regained physical integrity and demonstrated advances in neurologic functioning with intensive restorative therapy, John W. McDonald, M.D., Ph.D., reported during a poster presentation at the annual meeting of the American Neurological Association.

Dr. McDonald and his associates at Washington University in St. Louis and the Kennedy Krieger Institute in Baltimore studied 57 adults whose injuries occurred at least 1 year prior to enrollment. Complete data were available for a total of 48 patients who participated in therapy for at least 6 months.

Patients who received traditional therapy for 6 months or longer (n = 22) were compared with those who spent a similar length of time undergoing activity-based restorative therapy that included at least 3 hours a week of functional electrical stimulation cycle ergometry (n = 26).

Patients who participated in restorative therapy increased the muscle mass of their quadriceps an average of 30%, while muscle fat decreased by 44%. Stimulated muscle strength increased by 78%, and relative spasticity was reduced by 47%. These measurements were obtained using a Biodex machine to generate free movement and velocity-dependent resistance while measuring response. No differences were seen in nonstimulated muscles, Dr. McDonald reported.

One-third of patients undergoing traditional rehabilitation lost 10 or more points on the combined motor and sensory score (CMSS) of an impairment scale established by the American Spinal Injury Association. Just one patient receiving restorative therapy lost at least 10 CMSS points.

The 69% of patients who responded to restorative therapy (18 of 26) gained an average of 38 CMSS points over the course of the study. Eleven of the 26 patients undergoing restorative therapy also decreased their dose of the antispasticity agent baclofen or discontinued it altogether. The same was true for just 3 of 22 patients receiving traditional therapy.

The positive results of this pilot study point to the need for the larger, randomized trial, which is scheduled to get underway in 2006 and will enroll 400 patients, Dr. McDonald said.

SAN DIEGO — Patients with chronic spinal cord injury regained physical integrity and demonstrated advances in neurologic functioning with intensive restorative therapy, John W. McDonald, M.D., Ph.D., reported during a poster presentation at the annual meeting of the American Neurological Association.

Dr. McDonald and his associates at Washington University in St. Louis and the Kennedy Krieger Institute in Baltimore studied 57 adults whose injuries occurred at least 1 year prior to enrollment. Complete data were available for a total of 48 patients who participated in therapy for at least 6 months.

Patients who received traditional therapy for 6 months or longer (n = 22) were compared with those who spent a similar length of time undergoing activity-based restorative therapy that included at least 3 hours a week of functional electrical stimulation cycle ergometry (n = 26).

Patients who participated in restorative therapy increased the muscle mass of their quadriceps an average of 30%, while muscle fat decreased by 44%. Stimulated muscle strength increased by 78%, and relative spasticity was reduced by 47%. These measurements were obtained using a Biodex machine to generate free movement and velocity-dependent resistance while measuring response. No differences were seen in nonstimulated muscles, Dr. McDonald reported.

One-third of patients undergoing traditional rehabilitation lost 10 or more points on the combined motor and sensory score (CMSS) of an impairment scale established by the American Spinal Injury Association. Just one patient receiving restorative therapy lost at least 10 CMSS points.

The 69% of patients who responded to restorative therapy (18 of 26) gained an average of 38 CMSS points over the course of the study. Eleven of the 26 patients undergoing restorative therapy also decreased their dose of the antispasticity agent baclofen or discontinued it altogether. The same was true for just 3 of 22 patients receiving traditional therapy.

The positive results of this pilot study point to the need for the larger, randomized trial, which is scheduled to get underway in 2006 and will enroll 400 patients, Dr. McDonald said.

SAN DIEGO — Patients with chronic spinal cord injury regained physical integrity and demonstrated advances in neurologic functioning with intensive restorative therapy, John W. McDonald, M.D., Ph.D., reported during a poster presentation at the annual meeting of the American Neurological Association.

Dr. McDonald and his associates at Washington University in St. Louis and the Kennedy Krieger Institute in Baltimore studied 57 adults whose injuries occurred at least 1 year prior to enrollment. Complete data were available for a total of 48 patients who participated in therapy for at least 6 months.

Patients who received traditional therapy for 6 months or longer (n = 22) were compared with those who spent a similar length of time undergoing activity-based restorative therapy that included at least 3 hours a week of functional electrical stimulation cycle ergometry (n = 26).

Patients who participated in restorative therapy increased the muscle mass of their quadriceps an average of 30%, while muscle fat decreased by 44%. Stimulated muscle strength increased by 78%, and relative spasticity was reduced by 47%. These measurements were obtained using a Biodex machine to generate free movement and velocity-dependent resistance while measuring response. No differences were seen in nonstimulated muscles, Dr. McDonald reported.

One-third of patients undergoing traditional rehabilitation lost 10 or more points on the combined motor and sensory score (CMSS) of an impairment scale established by the American Spinal Injury Association. Just one patient receiving restorative therapy lost at least 10 CMSS points.

The 69% of patients who responded to restorative therapy (18 of 26) gained an average of 38 CMSS points over the course of the study. Eleven of the 26 patients undergoing restorative therapy also decreased their dose of the antispasticity agent baclofen or discontinued it altogether. The same was true for just 3 of 22 patients receiving traditional therapy.

The positive results of this pilot study point to the need for the larger, randomized trial, which is scheduled to get underway in 2006 and will enroll 400 patients, Dr. McDonald said.

BALTIMORE — Exercise provides health benefits to patients with spinal cord injuries, but whether exercise increases patients' sensation and ability to move, perhaps by stimulating repair of damaged nerves, is still an open question.

A new spinal cord injury center at Baltimore's Kennedy Krieger Institute offers an activity-based therapy plan for both children and adults with congenital, viral, or trauma-related spinal cord injury that emphasizes repetitive motion intended to awaken dormant nerves.

The centerpiece of activity-based therapy, sometimes called “advanced restoration” therapy, is a recumbent stationary bicycle. Patients pedal aided by electrodes attached to specific muscle groups. Some in-house patients also use a robotic walking machine known as Lokomat that operates the legs as the patient's upper body is suspended in a harness over a treadmill. All the equipment is designed to be adaptable for children.

Children may respond especially well to activity-based therapy because their central nervous systems are developing and their smaller, lighter bodies may be more receptive to any restorative or regenerative effects of these exercises, according to the center's director, neurologist John W. McDonald, M.D.

Although he thinks the therapy stimulates remyelinization, no trials have tested the process in humans. That's because no noninvasive imaging method has the necessary resolution for measuring cellular events, he explained.

Exercise was shown to improve the physical condition of the body, including such indicators as bone density, blood glucose level, muscle mass, and cardiovascular fitness, in 60 adults with spinal cord injuries who participated in a 3-year cohort study. These patients' spinal cord injuries were of at least 18 months' duration at the time of enrollment in the study, past the point when therapy is traditionally considered effective.

Dr. McDonald said the patients also experienced “useful improvement in movement and sensation” as a result of the exercise program.

He will present details of the data at the annual meeting of the American Neurological Association in San Diego in September. A prospective randomized trial examining activity-based therapy in children is underway at Philadelphia Shriners Hospital and Kennedy Krieger Institute and is about half completed, Dr. McDonald noted. He is planning a larger-scale prospective study in adults at Philadelphia Shriners Hospital, Shepherd Center in Atlanta, and Kennedy Krieger Institute.

Other researchers are less enthusiastic about repetitive motion therapy.

Traditional physical therapy is usually just as good, said Bruce H. Dobkin, M.D., program director of the neurologic rehabilitation and research program at the University of California, Los Angeles. His recent study at six sites across the United States and in Canada showed regular therapy yielded results similar to those of an experimental regimen of treadmill walking assisted by physical therapists.

Newer therapies may prove to be useful, according to Steven Kirshblum, M.D., of the Kessler Institute for Rehabilitation in West Orange, N.J.

Future effective treatments for patients with spinal cord injuries will probably combine drugs, surgery, exercise, and possibly stem cells, Dr. Kirshblum predicted.

BALTIMORE — Exercise provides health benefits to patients with spinal cord injuries, but whether exercise increases patients' sensation and ability to move, perhaps by stimulating repair of damaged nerves, is still an open question.

A new spinal cord injury center at Baltimore's Kennedy Krieger Institute offers an activity-based therapy plan for both children and adults with congenital, viral, or trauma-related spinal cord injury that emphasizes repetitive motion intended to awaken dormant nerves.

The centerpiece of activity-based therapy, sometimes called “advanced restoration” therapy, is a recumbent stationary bicycle. Patients pedal aided by electrodes attached to specific muscle groups. Some in-house patients also use a robotic walking machine known as Lokomat that operates the legs as the patient's upper body is suspended in a harness over a treadmill. All the equipment is designed to be adaptable for children.

Children may respond especially well to activity-based therapy because their central nervous systems are developing and their smaller, lighter bodies may be more receptive to any restorative or regenerative effects of these exercises, according to the center's director, neurologist John W. McDonald, M.D.

Although he thinks the therapy stimulates remyelinization, no trials have tested the process in humans. That's because no noninvasive imaging method has the necessary resolution for measuring cellular events, he explained.

Exercise was shown to improve the physical condition of the body, including such indicators as bone density, blood glucose level, muscle mass, and cardiovascular fitness, in 60 adults with spinal cord injuries who participated in a 3-year cohort study. These patients' spinal cord injuries were of at least 18 months' duration at the time of enrollment in the study, past the point when therapy is traditionally considered effective.

Dr. McDonald said the patients also experienced “useful improvement in movement and sensation” as a result of the exercise program.

He will present details of the data at the annual meeting of the American Neurological Association in San Diego in September. A prospective randomized trial examining activity-based therapy in children is underway at Philadelphia Shriners Hospital and Kennedy Krieger Institute and is about half completed, Dr. McDonald noted. He is planning a larger-scale prospective study in adults at Philadelphia Shriners Hospital, Shepherd Center in Atlanta, and Kennedy Krieger Institute.

Other researchers are less enthusiastic about repetitive motion therapy.

Traditional physical therapy is usually just as good, said Bruce H. Dobkin, M.D., program director of the neurologic rehabilitation and research program at the University of California, Los Angeles. His recent study at six sites across the United States and in Canada showed regular therapy yielded results similar to those of an experimental regimen of treadmill walking assisted by physical therapists.

Newer therapies may prove to be useful, according to Steven Kirshblum, M.D., of the Kessler Institute for Rehabilitation in West Orange, N.J.

Future effective treatments for patients with spinal cord injuries will probably combine drugs, surgery, exercise, and possibly stem cells, Dr. Kirshblum predicted.

BALTIMORE — Exercise provides health benefits to patients with spinal cord injuries, but whether exercise increases patients' sensation and ability to move, perhaps by stimulating repair of damaged nerves, is still an open question.

A new spinal cord injury center at Baltimore's Kennedy Krieger Institute offers an activity-based therapy plan for both children and adults with congenital, viral, or trauma-related spinal cord injury that emphasizes repetitive motion intended to awaken dormant nerves.

The centerpiece of activity-based therapy, sometimes called “advanced restoration” therapy, is a recumbent stationary bicycle. Patients pedal aided by electrodes attached to specific muscle groups. Some in-house patients also use a robotic walking machine known as Lokomat that operates the legs as the patient's upper body is suspended in a harness over a treadmill. All the equipment is designed to be adaptable for children.

Children may respond especially well to activity-based therapy because their central nervous systems are developing and their smaller, lighter bodies may be more receptive to any restorative or regenerative effects of these exercises, according to the center's director, neurologist John W. McDonald, M.D.

Although he thinks the therapy stimulates remyelinization, no trials have tested the process in humans. That's because no noninvasive imaging method has the necessary resolution for measuring cellular events, he explained.

Exercise was shown to improve the physical condition of the body, including such indicators as bone density, blood glucose level, muscle mass, and cardiovascular fitness, in 60 adults with spinal cord injuries who participated in a 3-year cohort study. These patients' spinal cord injuries were of at least 18 months' duration at the time of enrollment in the study, past the point when therapy is traditionally considered effective.

Dr. McDonald said the patients also experienced “useful improvement in movement and sensation” as a result of the exercise program.

He will present details of the data at the annual meeting of the American Neurological Association in San Diego in September. A prospective randomized trial examining activity-based therapy in children is underway at Philadelphia Shriners Hospital and Kennedy Krieger Institute and is about half completed, Dr. McDonald noted. He is planning a larger-scale prospective study in adults at Philadelphia Shriners Hospital, Shepherd Center in Atlanta, and Kennedy Krieger Institute.

Other researchers are less enthusiastic about repetitive motion therapy.

Traditional physical therapy is usually just as good, said Bruce H. Dobkin, M.D., program director of the neurologic rehabilitation and research program at the University of California, Los Angeles. His recent study at six sites across the United States and in Canada showed regular therapy yielded results similar to those of an experimental regimen of treadmill walking assisted by physical therapists.

Newer therapies may prove to be useful, according to Steven Kirshblum, M.D., of the Kessler Institute for Rehabilitation in West Orange, N.J.

Future effective treatments for patients with spinal cord injuries will probably combine drugs, surgery, exercise, and possibly stem cells, Dr. Kirshblum predicted.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.

SCOTTSDALE, ARIZ. — Physicians in Hawaii have described a mysterious nontraumatic myelopathy in seven young people who became weak and could not stand shortly after taking an otherwise uneventful surfing lesson.

Typically, the novices felt some discomfort or pain during the lesson but continued to surf for 15–20 minutes. They did not notice weakness or paresthesias until 10–60 minutes after the onset of symptoms.

By that time, they were sitting on the beach and could not get up. The patients all had symptoms of neurogenic bladder as well.

“We've done all this imaging to try to see what was going on with them. None of them had back fractures, but they had paraplegia—some for a couple of weeks,” Cherylee W.J. Chang, M.D., said at the annual meeting of the Neurocritical Care Society, where she described the cases in a poster.

All seven patients were treated acutely with methylprednisolone (Solu-Medrol). Over time, six patients improved by 1–3 grades on the Acute Spinal Injury Association impairment scale.

Paraplegia appears to be permanent in the oldest patient, a 31-year-old man from Illinois, according to Dr. Chang of the Queen's Medical Center in Honolulu, where she is medical director of the Neuroscience Institute and neurocritical care director of the stroke center.

Dr. Chang said she first heard of a similar case in 1997. After learning of a third surfer with nontraumatic myelopathy, she began collecting case reports. The four males and three females, aged 15–31 years, described in the poster were hospitalized at the Queen's Medical Center during June 2002 to July 2004.

Only one patient had surfed before. The common factor was a basic maneuver in which they hyperextended from a prone to a standing position on their surfboards. Dr. Chang theorized that the rapid movement probably put substantial pressure on their disks.

Plain films and CT scans did not find any fractures. Serologic and cerebrospinal fluid tests were negative, but lumbar punctures revealed elevated protein, along with increases in red and white blood cells. CT angiograms, done in three patients, showed no aortic dissection.

MRI of the spinal cord produced a clue in all but one patient: changes from T7, T8, or T10 to the conus. Several patients also had loss of disk height or small disk protrusions.

Based on these changes and the young age of the patients, Dr. Chang and her colleagues hypothesized that a rise in disk pressure might have caused extrusion of disk materials into small blood vessels leading to fibrocartilaginous embolization.

“In young people, the disk is still cartilaginous and kind of mushy and wet. In old people, it's probably fiber; if you squish it, it's not going anywhere,” she said, speculating that the cartilage had gotten “squished into the vein and into the spinal cord.”

“I can't prove that, because none of our patients died, thank goodness,” she said. “But it's the theory of why this might be happening.”

Dr. Chang is continuing to follow these patients. She said she has heard of a dozen cases at other hospitals in Hawaii and is curious to learn whether physicians have seen similar patients in other surfing communities.

MARCO ISLAND, FLA. — Posttraumatic stress disorder is not uncommon after moderate-to-severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, the researchers assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers did monthly assessments with the PTSD Checklist- Civilian Version, the Patient Health Questionnaire, and the Self-Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” he said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were common.

The investigators looked at PTSD symptom clusters and found arousal symptoms present in 23% of assessments over the 6 months. They also found intrusive symptoms in 20%, and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD. There also was a trend toward poorer self-reported health status among participants with PTSD.

The study was funded by NIH's National Center for Medical Rehabilitation Research.

MARCO ISLAND, FLA. — Posttraumatic stress disorder is not uncommon after moderate-to-severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, the researchers assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers did monthly assessments with the PTSD Checklist- Civilian Version, the Patient Health Questionnaire, and the Self-Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” he said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were common.

The investigators looked at PTSD symptom clusters and found arousal symptoms present in 23% of assessments over the 6 months. They also found intrusive symptoms in 20%, and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD. There also was a trend toward poorer self-reported health status among participants with PTSD.

The study was funded by NIH's National Center for Medical Rehabilitation Research.

MARCO ISLAND, FLA. — Posttraumatic stress disorder is not uncommon after moderate-to-severe traumatic brain injury, Jesse R. Fann, M.D., said at the annual meeting of the Academy of Psychosomatic Medicine.

Many people experience anxiety after moderate-to-severe traumatic brain injury. Because both brain injury and dissociation from posttraumatic stress disorder (PTSD) can impair declarative memory, the true occurrence of PTSD remains controversial, noted Dr. Fann, director of the psychiatry and psychology consultation service at the Seattle Cancer Care Alliance.

In a 6-month prospective follow-up study, the researchers assessed 124 patients admitted to Harborview Medical Center in Seattle following traumatic brain injury to determine the incidence of PTSD, the risk factors, and how PTSD symptoms manifest in this population.

Researchers did monthly assessments with the PTSD Checklist- Civilian Version, the Patient Health Questionnaire, and the Self-Reported Health Status (SF-1) instruments. The first month had the highest incidence of PTSD, about 13%. “A lot of the PTSD may not be prolonged, lasting 1–3 months,” he said.

Patients with lower levels of education and those injured in an assault were significantly more likely to meet criteria for the disorder. Participants who met PTSD criteria most commonly reported feeling sad when recalling aspects of the event and feeling cut off from others, jumpy, hypervigilant, and irritable. Sleep disturbances were common.

The investigators looked at PTSD symptom clusters and found arousal symptoms present in 23% of assessments over the 6 months. They also found intrusive symptoms in 20%, and avoidance and numbing in 8%.

“There is a significant overlap of other comorbid psychiatric disorders, such as anxiety and depression, that can present a diagnostic challenge,” Dr. Fann said. “There is also overlap of PTSD and traumatic brain injury symptoms.”

The researchers also assessed patients for major depressive disorder, panic disorder, and other anxiety disorders. PTSD was significantly associated with current major depression, any other anxiety disorder, a blood alcohol level greater than 0.08, and a psychiatric history, according to a univariate analysis. A logistic regression analysis showed that people with a history of PTSD reported significantly increased functional impairment compared with those without PTSD. There also was a trend toward poorer self-reported health status among participants with PTSD.

The study was funded by NIH's National Center for Medical Rehabilitation Research.

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports-related injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002. A chart review revealed 64 sports-related injuries, 15 (23%) of which were golf-related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fractures, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fractures in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%).

Six children required neurosurgical procedures for their injuries. Twelve patients made full recoveries, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up. Another child required permanent shunt placement and underwent multiple shunt revisions due to device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. Augusta, where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the more widespread use of golf carts also contributes to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart. In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports-related injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002. A chart review revealed 64 sports-related injuries, 15 (23%) of which were golf-related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fractures, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fractures in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%).

Six children required neurosurgical procedures for their injuries. Twelve patients made full recoveries, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up. Another child required permanent shunt placement and underwent multiple shunt revisions due to device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. Augusta, where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the more widespread use of golf carts also contributes to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart. In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

As the number of children taking to the links has steadily risen, so too has the number of pediatric golf-related head injuries.

Golf-related accidents were the second most common cause of sports-related injury, after bicycle use, among 2,546 patients younger than 19 years who were evaluated by neurosurgeons for any cause at the Medical College of Georgia in Augusta between 1996 and 2002. A chart review revealed 64 sports-related injuries, 15 (23%) of which were golf-related, according to Scott Y. Rahimi, M.D., lead author and neurosurgery resident at the medical college.

Seven of the golf injuries were caused by golf cart accidents, seven by golf clubs, and one by a golf ball (J. Neurosurg. [Pediatrics 2] 2005;102:163–6).

The mean age of the children in the study was 7 years, and the youngest was 9 months.

The most common injury was depressed skull fractures, which occurred in 7 (47%) of the 15 cases, followed by nondisplaced skull fractures in 3 (20%), subarachnoid hemorrhage in 2 (13%), epidural hematoma in 2 (13%), and subdural hematoma in 1 (6%).

Six children required neurosurgical procedures for their injuries. Twelve patients made full recoveries, including nine patients who were managed conservatively.

One child developed chronic headaches after a 3-year follow-up. Another child required permanent shunt placement and underwent multiple shunt revisions due to device malfunction. One child died due to uncontrollable cerebral edema following a golf-cart accident.

A review of the literature by the investigators found that not only are golf-related injuries increasing, but they are the leading type of sports injury in regions where golf is popular, Dr. Rahimi and his colleagues wrote. Augusta, where this research was conducted, is home of the Masters Golf Tournament and a hotbed of golf enthusiasm.

The authors cite a 1997 review of head injuries at the Westchester Medical Center in New York in the 3-month period following Tiger Woods' first Masters championship. The review showed that of the eight children who required surgery for their head injury, half had a depressed skull fracture from a golf club. No similar golf injuries were seen in the 12 months prior to Mr. Woods' win (Surg. Neurol. 1998;50:608).

A report by the Consumer Product Safety Commission identified 19 deaths between 1973 and 1996 that were a direct consequence of children playing with golf clubs (Percept. Mot. Skills 1998;86:747–53).

Golf-related injuries most often involve golf clubs and balls and occur at parks and homes, rather than at golf courses.

Still, the author noted, the more widespread use of golf carts also contributes to the increase in accidents.

As a way to prevent or reduce injuries, Dr. Rahimi and his colleagues recommended precautionary guidelines and safety training programs, proper storage of golf clubs, adult supervision of golf-club and golf-cart use, and the requirement of a minimum legal age to drive a golf cart. In Georgia and many other states, it is illegal to drive a golf cart without a valid driver's license.

SCOTTSDALE, ARIZ. — The validity of large, randomized multicenter clinical trials to evaluate treatments for traumatic brain injury was called into question by numerous speakers during the annual meeting of the Neurocritical Care Society.

Speaking on therapeutic hypothermia, Donald Marion, M.D., refused to condemn the treatment when its promise in small single-hospital studies was not borne out in a large, randomized, multicenter trial, the findings of which showed the regimen was no better than current therapies.

Dr. Marion, a neurosurgeon and senior research fellow at the Brain Trauma Foundation, New York, took aim at the process. “Are valid multicenter clinical trials for severe traumatic brain injury possible?” he asked in a leadoff presentation, which became the talk of a 3-day meeting “I really think there is something about phase III trials that impact the outcomes independent of the treatment you are trying to use.”

Large, randomized, multicenter trials might be unsuited to the realities of neurocritical care for head trauma, according to Dr. Marion. The cases are too complicated “with multiple physiological variables that can affect outcome and, unfortunately, multiple critical care physicians making treatment decisions,” he said, adding that patients with traumatic brain injury often have other severe injuries that further complicate their randomization.

Dr. Marion estimated that 15-20 drugs, including tirilazad mesylate, have failed multicenter trials in traumatic brain injury.

These physicians have strong individual biases that make complying with uniform protocols difficult, especially if the investigators are working at many different centers, he continued. Consistency within a center may make single-center studies a better measure of new treatments for head trauma, he suggested.

“My bias is very strongly that there is a lot of noise in multicenter trials that may have drowned out the potential benefit of a lot of therapies in the past,” he said.

As chair of the hypothermia session, Michael N. Diringer, M.D., of Washington University, St. Louis, expressed surprise: “This is the first time I've heard someone argue we might want to think twice about how we interpret the results from multicenter trials,” he said. “The ability to perform trials on very sick, very complicated patients across centers—to get everybody to do the same thing—is an enormous and maybe potentially impossible task.”

Stefan Schwab, M.D., also complained of inconsistent protocols as a major problem in his talk on therapeutic hypothermia for stroke. However, he disagreed with Dr. Marion's position. Studies have used different temperatures, times to cooling, duration of cooling, etc., according to Dr. Schwab of the University of Heidelberg in Germany. What is needed, he said, is one large, randomized, multicenter trial with agreed-upon protocols.

“In my view, just randomized trials can show whether there is significance,” he said, arguing that small studies can be too selective. “Pick one right patient in one center and one right patient in another center and you come up with 20 right patients overall,” he said. “We want to treat patients with stroke with hypothermia all over the world.”

Raj K. Narayan, M.D., of the University of Cincinnati, argued that therapeutic hypothermia should not be a standard therapy, so long as it passes muster only in small studies. “Large randomized trials have some limitations, and certainly small trials have limitations. Just so long as we are all aware what those limitations are, large randomized trials are, in general, one of the strongest ways of figuring things out,” he said.

For Maxwell S. Damian, M.D., of the University of Leicester, England, the issues raised by Dr. Marion are a concern as his group advances beyond its single-center study of hypothermia in combination with coenzyme Q10 for head trauma. “That actually has been influencing our multicenter trial,” he said. “We are restricting it to people we know personally who have a similar regimen of hypothermia. It's a big problem—method.”

Another researcher, Michael F. Stiefel, M.D., of the University of Pennsylvania, Philadelphia, ruled out randomized trials in his group's work on brain tissue oxygen monitoring. He said it is now standard at his hospital based on data from a single-center study presented at the meeting.

“A lot of what we do in neurosurgery has never been randomized. We use something, and we see if it works. That's what we do. We wouldn't feel comfortable randomizing now.” he said.

SCOTTSDALE, ARIZ. — The validity of large, randomized multicenter clinical trials to evaluate treatments for traumatic brain injury was called into question by numerous speakers during the annual meeting of the Neurocritical Care Society.

Speaking on therapeutic hypothermia, Donald Marion, M.D., refused to condemn the treatment when its promise in small single-hospital studies was not borne out in a large, randomized, multicenter trial, the findings of which showed the regimen was no better than current therapies.

Dr. Marion, a neurosurgeon and senior research fellow at the Brain Trauma Foundation, New York, took aim at the process. “Are valid multicenter clinical trials for severe traumatic brain injury possible?” he asked in a leadoff presentation, which became the talk of a 3-day meeting “I really think there is something about phase III trials that impact the outcomes independent of the treatment you are trying to use.”

Large, randomized, multicenter trials might be unsuited to the realities of neurocritical care for head trauma, according to Dr. Marion. The cases are too complicated “with multiple physiological variables that can affect outcome and, unfortunately, multiple critical care physicians making treatment decisions,” he said, adding that patients with traumatic brain injury often have other severe injuries that further complicate their randomization.

Dr. Marion estimated that 15-20 drugs, including tirilazad mesylate, have failed multicenter trials in traumatic brain injury.

These physicians have strong individual biases that make complying with uniform protocols difficult, especially if the investigators are working at many different centers, he continued. Consistency within a center may make single-center studies a better measure of new treatments for head trauma, he suggested.

“My bias is very strongly that there is a lot of noise in multicenter trials that may have drowned out the potential benefit of a lot of therapies in the past,” he said.

As chair of the hypothermia session, Michael N. Diringer, M.D., of Washington University, St. Louis, expressed surprise: “This is the first time I've heard someone argue we might want to think twice about how we interpret the results from multicenter trials,” he said. “The ability to perform trials on very sick, very complicated patients across centers—to get everybody to do the same thing—is an enormous and maybe potentially impossible task.”

Stefan Schwab, M.D., also complained of inconsistent protocols as a major problem in his talk on therapeutic hypothermia for stroke. However, he disagreed with Dr. Marion's position. Studies have used different temperatures, times to cooling, duration of cooling, etc., according to Dr. Schwab of the University of Heidelberg in Germany. What is needed, he said, is one large, randomized, multicenter trial with agreed-upon protocols.

“In my view, just randomized trials can show whether there is significance,” he said, arguing that small studies can be too selective. “Pick one right patient in one center and one right patient in another center and you come up with 20 right patients overall,” he said. “We want to treat patients with stroke with hypothermia all over the world.”

Raj K. Narayan, M.D., of the University of Cincinnati, argued that therapeutic hypothermia should not be a standard therapy, so long as it passes muster only in small studies. “Large randomized trials have some limitations, and certainly small trials have limitations. Just so long as we are all aware what those limitations are, large randomized trials are, in general, one of the strongest ways of figuring things out,” he said.

For Maxwell S. Damian, M.D., of the University of Leicester, England, the issues raised by Dr. Marion are a concern as his group advances beyond its single-center study of hypothermia in combination with coenzyme Q10 for head trauma. “That actually has been influencing our multicenter trial,” he said. “We are restricting it to people we know personally who have a similar regimen of hypothermia. It's a big problem—method.”

Another researcher, Michael F. Stiefel, M.D., of the University of Pennsylvania, Philadelphia, ruled out randomized trials in his group's work on brain tissue oxygen monitoring. He said it is now standard at his hospital based on data from a single-center study presented at the meeting.

“A lot of what we do in neurosurgery has never been randomized. We use something, and we see if it works. That's what we do. We wouldn't feel comfortable randomizing now.” he said.

SCOTTSDALE, ARIZ. — The validity of large, randomized multicenter clinical trials to evaluate treatments for traumatic brain injury was called into question by numerous speakers during the annual meeting of the Neurocritical Care Society.

Speaking on therapeutic hypothermia, Donald Marion, M.D., refused to condemn the treatment when its promise in small single-hospital studies was not borne out in a large, randomized, multicenter trial, the findings of which showed the regimen was no better than current therapies.

Dr. Marion, a neurosurgeon and senior research fellow at the Brain Trauma Foundation, New York, took aim at the process. “Are valid multicenter clinical trials for severe traumatic brain injury possible?” he asked in a leadoff presentation, which became the talk of a 3-day meeting “I really think there is something about phase III trials that impact the outcomes independent of the treatment you are trying to use.”

Large, randomized, multicenter trials might be unsuited to the realities of neurocritical care for head trauma, according to Dr. Marion. The cases are too complicated “with multiple physiological variables that can affect outcome and, unfortunately, multiple critical care physicians making treatment decisions,” he said, adding that patients with traumatic brain injury often have other severe injuries that further complicate their randomization.

Dr. Marion estimated that 15-20 drugs, including tirilazad mesylate, have failed multicenter trials in traumatic brain injury.

These physicians have strong individual biases that make complying with uniform protocols difficult, especially if the investigators are working at many different centers, he continued. Consistency within a center may make single-center studies a better measure of new treatments for head trauma, he suggested.

“My bias is very strongly that there is a lot of noise in multicenter trials that may have drowned out the potential benefit of a lot of therapies in the past,” he said.

As chair of the hypothermia session, Michael N. Diringer, M.D., of Washington University, St. Louis, expressed surprise: “This is the first time I've heard someone argue we might want to think twice about how we interpret the results from multicenter trials,” he said. “The ability to perform trials on very sick, very complicated patients across centers—to get everybody to do the same thing—is an enormous and maybe potentially impossible task.”

Stefan Schwab, M.D., also complained of inconsistent protocols as a major problem in his talk on therapeutic hypothermia for stroke. However, he disagreed with Dr. Marion's position. Studies have used different temperatures, times to cooling, duration of cooling, etc., according to Dr. Schwab of the University of Heidelberg in Germany. What is needed, he said, is one large, randomized, multicenter trial with agreed-upon protocols.

“In my view, just randomized trials can show whether there is significance,” he said, arguing that small studies can be too selective. “Pick one right patient in one center and one right patient in another center and you come up with 20 right patients overall,” he said. “We want to treat patients with stroke with hypothermia all over the world.”

Raj K. Narayan, M.D., of the University of Cincinnati, argued that therapeutic hypothermia should not be a standard therapy, so long as it passes muster only in small studies. “Large randomized trials have some limitations, and certainly small trials have limitations. Just so long as we are all aware what those limitations are, large randomized trials are, in general, one of the strongest ways of figuring things out,” he said.

For Maxwell S. Damian, M.D., of the University of Leicester, England, the issues raised by Dr. Marion are a concern as his group advances beyond its single-center study of hypothermia in combination with coenzyme Q10 for head trauma. “That actually has been influencing our multicenter trial,” he said. “We are restricting it to people we know personally who have a similar regimen of hypothermia. It's a big problem—method.”

Another researcher, Michael F. Stiefel, M.D., of the University of Pennsylvania, Philadelphia, ruled out randomized trials in his group's work on brain tissue oxygen monitoring. He said it is now standard at his hospital based on data from a single-center study presented at the meeting.

“A lot of what we do in neurosurgery has never been randomized. We use something, and we see if it works. That's what we do. We wouldn't feel comfortable randomizing now.” he said.

PHOENIX, ARIZ. — Magnetic resonance imaging provides more detail about traumatic brain and spinal cord injuries but computerized tomography is much faster, according to a colonel in the U.S. Army Medical Corps who served in Afghanistan.

In head traumas, MRI is superior for all pathologies except skull fracture and acute subarachnoid hemorrhage, Geoffrey S.F. Ling, M.D., said at a meeting sponsored by the Society of Critical Care Medicine. It can give far more information about edema, diffuse axonal injury, contusions, hematomas, and posterior fossa lesions, but these can all be diagnosed more quickly with CT scans, he said; rarely does information gathered with an MRI change clinical management of the patient.

Consequently, Dr. Ling, director of the division of critical care medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., said he reserves use of MRI to establish a diagnosis in a patient who is not improving after several days in an intensive care unit and to establish a prognosis.

Dr. Ling recommended CT scans for all patients at high risk for intracranial pathology. These would include patients with focal neural signs, penetrating wounds, depressed skull fractures that are palpable, and impaired motor skills in the absence of alcohol or drugs.

CT scans should also be considered in moderate-risk cases: patients with a history of changed mental status, amnesia, progressive headache, serious facial injury, vomiting, evidence of a skull fracture, multiple traumas, possible child abuse, and age younger than 2 years.

“If the patient was knocked out for more than 5 minutes, I would go ahead and do a CT scan,” he said. Plain x-rays should be used only in cervical spine injuries such as whiplash, for which they can diagnose tiny fractures, according to Dr. Ling. “The only time I will use plain films is for the neck,” he said.

PHOENIX, ARIZ. — Magnetic resonance imaging provides more detail about traumatic brain and spinal cord injuries but computerized tomography is much faster, according to a colonel in the U.S. Army Medical Corps who served in Afghanistan.

In head traumas, MRI is superior for all pathologies except skull fracture and acute subarachnoid hemorrhage, Geoffrey S.F. Ling, M.D., said at a meeting sponsored by the Society of Critical Care Medicine. It can give far more information about edema, diffuse axonal injury, contusions, hematomas, and posterior fossa lesions, but these can all be diagnosed more quickly with CT scans, he said; rarely does information gathered with an MRI change clinical management of the patient.

Consequently, Dr. Ling, director of the division of critical care medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., said he reserves use of MRI to establish a diagnosis in a patient who is not improving after several days in an intensive care unit and to establish a prognosis.

Dr. Ling recommended CT scans for all patients at high risk for intracranial pathology. These would include patients with focal neural signs, penetrating wounds, depressed skull fractures that are palpable, and impaired motor skills in the absence of alcohol or drugs.

CT scans should also be considered in moderate-risk cases: patients with a history of changed mental status, amnesia, progressive headache, serious facial injury, vomiting, evidence of a skull fracture, multiple traumas, possible child abuse, and age younger than 2 years.

“If the patient was knocked out for more than 5 minutes, I would go ahead and do a CT scan,” he said. Plain x-rays should be used only in cervical spine injuries such as whiplash, for which they can diagnose tiny fractures, according to Dr. Ling. “The only time I will use plain films is for the neck,” he said.

PHOENIX, ARIZ. — Magnetic resonance imaging provides more detail about traumatic brain and spinal cord injuries but computerized tomography is much faster, according to a colonel in the U.S. Army Medical Corps who served in Afghanistan.

In head traumas, MRI is superior for all pathologies except skull fracture and acute subarachnoid hemorrhage, Geoffrey S.F. Ling, M.D., said at a meeting sponsored by the Society of Critical Care Medicine. It can give far more information about edema, diffuse axonal injury, contusions, hematomas, and posterior fossa lesions, but these can all be diagnosed more quickly with CT scans, he said; rarely does information gathered with an MRI change clinical management of the patient.

Consequently, Dr. Ling, director of the division of critical care medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md., said he reserves use of MRI to establish a diagnosis in a patient who is not improving after several days in an intensive care unit and to establish a prognosis.

Dr. Ling recommended CT scans for all patients at high risk for intracranial pathology. These would include patients with focal neural signs, penetrating wounds, depressed skull fractures that are palpable, and impaired motor skills in the absence of alcohol or drugs.

CT scans should also be considered in moderate-risk cases: patients with a history of changed mental status, amnesia, progressive headache, serious facial injury, vomiting, evidence of a skull fracture, multiple traumas, possible child abuse, and age younger than 2 years.

“If the patient was knocked out for more than 5 minutes, I would go ahead and do a CT scan,” he said. Plain x-rays should be used only in cervical spine injuries such as whiplash, for which they can diagnose tiny fractures, according to Dr. Ling. “The only time I will use plain films is for the neck,” he said.