I am currently in PA school and was procrastinating my studies (taking a coffee/T.V. break) when I was forced by my remote control to watch the NOVA program. I am glad that I took the time to learn that other trauma centers are not implementing this procedure. I am interested in creating a thesis topic which encourages the use of ventriculostomy catheters. I have already done a preliminary Medline search. Do you have any further suggestions? Very few people get a chance to make such a profound difference in someone's life. You are a hero.
Respectfully,

Brooke
Biddeford, ME
sunshine@lamere.net

Ventriculostomy catheters are the gold standard for intracranial pressure monitoring and treatment, mainly because they've been used historically and are the reference standard for ICP monitoring. In addition, they're therapeutic because you can drain cerebral spinal fluid in the event that the pressure in the head gets too high. The references for ICP. monitoring are in the guidelines and I suggest you call the Aitken Neuroscience Center for further information at (212) 772-6426.

Dr. Ghajar,
Fascinating documentary, and fascinating work! Because of the blood-brain barrier, I assume that the cerebral-spinal fluid that is drained from the trauma victims' heads is the medium of transport for oxygen and nutrients to the brain. How do you ensure that you don't drain away too much of this fluid? In other words, how do you know that there's enough cerebral-spinal fluid left for the brain to get oxygen and nourishment? P.S. A friend recently took CPR training here, and was told that monitoring and relieving the ICP was routine for head-trauma patients. Gratifying to know that what you're trying to instill universally, is taken for granted here.

Carla Wobschall
Mandan, ND
wobsch@tic.bisman.com

When we drain cerebral spinal fluid in patients that are in a coma from severe head injury, we do not drain too much of it away because the brain makes 500 cc's a day and we only drain to a certain pressure. The brain makes this fluid to act as a cushion for the brain but it's also involved in draining the edema fluid in the brain—as a sort of lymphatic system.

Dr. Ghajar,
I thoroughly enjoyed the NOVA special about COMA. I recently graduated as a speech pathologist and hope to one day work with people with brain injuries again. After the show, I found myself thinking about my internship on the TBI unit of Braintree Rehabilitation Hospital in Massachusetts and about how different my patients might have been if your technique was utilized when the injuries first occurred. My question is what are the reasons why a patient would not turn out as well as those profiled on the special? Why do 10-20% remain in a vegetative state? Another question is do you know where I can find a list of the trauma hospitals and rehabilitation centers in New York that have Traumatic Brain Injury units?
Thank you very much!



Debra
Forest Hills, NY
Debra@pipeline.com

Five to 10 percent of patients remain in vegetative state, probably because at the time of accident or immediately thereafter they did not receive enough oxygen or blood flow because the patient was not breathing or had a low blood pressure. That percentage of patients who remain in vegetative state seems to be a fixed amount from one study to another, indicating there's probably something that occurs at the time of the accident. There are a couple of reasons why patients would not turn out as well as those profiled on the special; one is that patients who have a very severe primary injury (that means injury at the time of the accident) may have such overwhelming brain injuries that no matter what you do, they would have a poor outcome. However the majority of patients do not have a devastating brain injury if they arrive in the emergency room or remain in the hospital for a few days. Some of the reasons for poor outcome are documented in studies showing that patients that are hyperventilated persistently in the intensive care unit do not make as good a recovery as patients who are not hyperventilated. However sometimes we have to use hyperventilation when patients are showing signs of extreme brain swelling. In New York state they have organized traumatic brain injury coma recovery units. You should call Bill Reynolds at the Dept of Health in Albany. He initiated the program in New York state and would have a list of those units.

How important is it to monitor the brain pressure of patients with head injuries requiring hospitalization but who are not in comas? Are these patients susceptible to ongoing brain injury in the hours and days after an accident? Under what conditions is a ventriculostomy warranted in conscious patients? What non-invasive ways of monitoring brain pressure are being developed to make sure patients remain at safe cranial pressures?

Dr. Brian Von Herzen
Los Altos, CA
brianvon@best.com

There's no scientific evidence right now that patients who are not in coma from severe head injury (those that are either awake or sleepy) should have ICP monitoring. These patients have a less than 10 percent chance of having high pressure in their head and usually make a good outcome. However, there is much to be done in terms of investigating why these patients have problems with attention, memory, and headaches afterwards, even though their injuries seem quite minor at the time. We normally do not place ventriculostomy catheters in conscious patients for the reasons mentioned above.

Dr. Ghajar:
Are there no physiological indications in the monitoring of coma patients that determine the probability of the patient awakening from the vegetative state?

Your response to the question about cooling the brain to reduce pressure was interesting to me since the most effective and fast acting migraine medicine that I've used is from a Chinese herbalist that works by reducing the heat in the head.

Finally, as I'm involved in film and television, I want to applaud you for even allowing film crews into the hospitals under such critical and unpredictable circumstances. It's a testament to your confidence in the guidelines and to the competence of the staff. Thank you for raising the standard of medicine and science worldwide.



Georgette Deemer
Honolulu, HI
gdeemer@pixi.com

There is a study ongoing at Cornell University Medical College headed by Dr. Fred Plum, Chairman of Neurology, studying vegetative patients in order to see what parts of the brain are actually functioning. This is being done using PET (positron emission tomography) scanning. They have some very interesting preliminary work and in the future we may be able to say which parts of the brain are working and which are compatible with quality of life. Usually in adults we have to wait at least six months, in children one year, to be certain whether a person's going to end up in a persistent vegetative state.

The question is in regard to a young adult who is comatose due to cerebral anoxia. She responds to pain by withdrawal and arouses to loud noise, opens her eyes but does not track, has no voluntary movement or communication.

Has there been any experimentation with injecting fetal brain cells to see if these could help replace some of the cells lost?

Do I sound desperate?

Judith Andrews
Oklahoma City, OK
jandrews@msn.com

The Aitken Neuroscience Center, in collaboration with Dr. Steve Goldman at Cornell University Medical College, is doing active laboratory research in functional brain regeneration. There are cells in the brain that are capable of regeneration and we are now working out a method to develop enough of these cells and, in the future, may be able to transport them to regenerate a brain that has been destroyed by trauma, stroke, or Alzheimer's disease. At this point it is just basic laboratory research but we're hoping that in the future this may turn into a reality.

What are some of the wrong ways to treat a patient with a head injury, beginning with the EMT teams initial treatment, and what are some of the possible outcomes (other than the obvious of course)?

Lythande
Gambier, OH
lythande@ecr.net

We know from clinical studies that patients who have low blood pressure coming into the emergency room have a much worse outcome than patients with normal blood pressure. These factors—such as low blood pressure, lack of oxygen, and prolonged severe hyperventilation—can lead to global brain damage and death.

My father (age 79) suffered a severe head injury on June 25, 1997. He had two operations to remove blood and fluid. He now seems to be coming out of his vegetative state and will nod yes or no to simple questions. He also will move his foot upon request when awake. Will his age be a major factor in his ability to recover at some level? He was a healthy, active person before his accident.

Noreen Olek
Hamburg, NY
Noraven@juno.com

The guidelines for managing severe head injury are a living document and we're continually adding new chapters. One of the chapters that we've just finished is early prognostic indicators; we've found it's been known in the literature for quite some time that age is a significant predictor of outcome. There is a significant decrease in good outcome in the older population.

With pediatric patients, are indications for ICP monitoring significantly changed? Especially the blood pressure factor? Assume not newborn, but 1-2 years old. Do the actions of glucocorticoids remain the same in these patients as in adults?

Patricia M. Gibson
Orlando, FL
GagaGibson@classic.msn.com

The guidelines document is adding new chapters and one of them is pediatric indications. So far the early report is there are no significant differences right now in terms of ICP monitoring and they should be used in pediatric patients. At NY hospital Cornell Pediatric Intensive Care unit, children who have severe head injury all have ventriculostomy ICP monitoring and the blood pressure is raised if the intracranial pressure is too high. Glucocorticoids are not good at reducing intracranial pressure or improving outcome in adults and in most of the studies children were also included and so the conclusion must be the same. I don't know of any studies where they've done specifically children of one to two years old. It's a very small group and will require many years of study.