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favored hypotheses for the better part of a century were vasoparalysis (suggested by Fischer in 1870) or an arrest of circulation by an instantaneous rise in intracranial pressure (proposed by Strohmeyer in 1864 and popularized by Trotter in 1932) Jefferson, in his essay on the nature of concussion (1944), convincingly refuted these vascular hypotheses Later, Shatsky and coworkers, by the use of high-speed cineangiography, showed displacement of vessels but no arrest of circulation immediately after impact Beginning with the work of Denny-Brown and Russell in 1941, the physical factors involved in head and brain injury have been subjected to careful analysis These investigators demonstrated, in the monkey and cat, that concussion resulted when the freely moving head was struck by a heavy mass If the head was prevented from moving at the moment of impact, the same degree of force invariably failed to produce concussion More recently, the importance of head motion per se was veri ed by Gennarelli and colleagues, who were able to induce concussion in primates by rapid acceleration of the head without impact, a condition that rarely occurs in humans Holbourn, a Cambridge physicist, from a study of gelatin models under conditions simulating head trauma, deduced that when the head is struck, movement of the partly tethered but suspended brain always lags (due to inertia); but inevitably the brain moves also, and when it does it must rotate, for it occupies a round skull whose motions (because of attachment to the neck) usually describe an arc Pudenz and Sheldon and later Ommaya and coworkers (1974) proved the correctness of this assumption by photographing the brain through a transparent (Lucite) calvarium at the moment of impact The brain is thus subjected to shearing stresses set up by rotational forces mainly in the sagittal plane centered at its point of tethering in the high midbrain and subthalamus The torque at the level of the upper reticular formation would explain the immediate loss of consciousness, as described below Also, these rotational movements of the brain provide a reasonable explanation for the occurrence of surface injuries in certain places, ie, where the swirling brain comes into contact with bony prominences on the inner surface of the skull (petrous and orbital ridges, sphenoid wings), and of injuries to the corpus callosum, which is ung against the falx These views on the site and mechanism of concussion have been supported by a number of additional physiologic observations Foltz and Schmidt, in 1956, suggested that the reticular formation of the upper brainstem was the anatomic site of concussive injury They showed that in the concussed monkey, lemniscal sensory transmission through the brainstem was unaltered, but its effect in activating the high reticular formation was blocked They also demonstrated that the electrical activity of the medial reticular formation was depressed for a longer time and more severely than that of the cerebral cortex In 1956 and again in 1961, Strich described the neuropathologic ndings in patients who died months after severe closed head injuries that had caused immediate and protracted coma In all of her cases in which there were no signs of skull fracture, raised intracranial pressure, or gross subarachnoid hemorrhage she observed an uneven but diffuse degeneration of the cerebral white matter In cases of shorter survival (up to 6 weeks), she observed ballooning and interruption of axis cylinders These ndings were subsequently con rmed by Nevin, by J H Adams and colleagues, and by Gennarelli and coworkers, the last of these groups working with monkeys It is noteworthy that in most of these cases, and subsequent ones reported by Jellinger and Seitelberger, there were. rdlc pdf 417 PDF417 Barcode Creating Library for RDLC Reports | Generate ...
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