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also lesions in the region of the reticular activating system and small hemorrhagic softenings in the corpus callosum, superior cerebellar peduncles, and dorsolateral tegmentum of the midbrain Strich interpreted the extensive white matter lesions, both in the hemispheres and in the brainstem, to represent a degeneration of nerve bers that had been stretched or torn by the shear stresses set up during rotational acceleration of the head (diffuse axonal injury), as had been postulated earlier by Holbourn She suggested that if nerve bers are stretched rather than torn, the lesions may be reversible and may play a part in the mechanism of concussion Symonds elaborated this view and saw in the shearing stresses which are maximal at the point where the cerebral hemispheres rotate on the relatively xed brainstem (ie, at the midbrain-subthalamic level) the explanation of concussion The extension of this idea, namely that diffuse axonal injury throughout the cerebral white matter is the main cause of persistent unconsciousness, has been widely adopted but as we discuss further on is open to dispute Indeed, even the proponents of diffuse axonal injury as an important effect of severe brain damage have found that thalamic lesions are almost always present in cases of prolonged coma or the persistent vegetative state (Adams et al 2000) Clinical Manifestations of Concussion The immediate abolition of consciousness, suppression of re exes (falling to the ground if standing), transient arrest of respiration, a brief period of bradycardia, and fall in blood pressure following a momentary rise at the time of impact are the characteristic clinical signs of concussive injury Rarely, if these abnormalities are suf ciently intense, death may occur at the moment of impact, presumably from respiratory arrest Usually the vital signs return to normal and stabilize within a few seconds while the patient remains unconscious Brief tonic extension of the limbs, clonic convulsive movements lasting up to about 20 seconds and other peculiar movements may occur immediately after the loss of consciousness (see McCrory et al) These concussive convulsions are probably of little signi cance and have not been shown to confer an increased risk of future seizures McCrory and colleagues noted an association between motor and convulsive movements and facial impact, and we have seen this feature twice in teenagers who collided while pursuing a ball The plantar re exes are transiently extensor Then, after a variable period of time, the patient begins to stir and opens his eyes but is unseeing Corneal, pharyngeal, and cutaneous re exes, originally depressed, return, and the limbs are withdrawn from painful stimuli Gradually contact is made with the environment, and the patient begins to obey simple commands and respond slowly and inadequately to simple questions Memories are not formed during this period; the patient may even carry on a conversation which, later on, he cannot recall Finally there is full recovery, corresponding to the time when the patient can form consecutive memories of current experiences The time required for the patient to pass through these stages of recovery may be only a few seconds or minutes, several hours, or possibly days; but again, between these extremes there are only quantitative differences, varying with the intensity of the process To the observer, such patients are comatose only from the moment of injury until they open their eyes and begin to speak; however, for the patient, the period of unconsciousness extends from a point before the injury occurred (retrograde amnesia) until the time when he is able to form consecutive memories at the end of the period of anterograde amnesia The duration of the amnesic period, particularly of anterograde amnesia, is the most reliable index of.

the severity of the concussive injury If there is no disturbance or loss of consciousness, none of the lesions described below are likely to be found More recently, the notion has been introduced that momentary stunning represents the mildest degree of concussion This state has found its way into various guidelines for the management of sports injuries, but there is no reason at the moment to presume it shares the same mechanism as concussion

items, formatting objects, texts, images, and parameters that defines a Web page Web templates can be either very basic or customized to the customer s needs, depending on their uses in the overall reporting process Therefore, the WAD user primarily needs to be aware of the applications and uses of each of the Web items in the process of creating and maintaining Web templates Finally, when the Web templates are executed in the Enterprise Portal, they are referred to as Web applications A Web application can be any combination of Web templates linked together The Web application design comprises a broad spectrum of Web-based business intelligence scenarios, which you can adjust to meet your individual needs using standard Web technologies Figure 3-1 shows how the Web Application Designer is integrated into the function landscape and tool landscape of the Business Explorer

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In fatal cases of head injury, the brain is often bruised, swollen, and lacerated and there may be hemorrhages, either meningeal or intracerebral, and hypoxic-ischemic lesions The prominence of these pathologic ndings was responsible for the long-prevailing view that cerebral injuries are largely a matter of bruises (contusions), hemorrhages, and the need for urgent operations That this can hardly be the case is indicated by the fact that some patients survive and make an excellent recovery from head injuries that are clinically as severe or almost as severe as the fatal ones One can only conclude, therefore, that most of the immediate symptoms of severe head injury depend on histologically invisible and highly reversible functional changes, including those underlying concussion The effects of bruises, lacerations, hemorrhages, localized swellings, white matter necroses, and herniations of tissue should not be minimized, since they are probably responsible for or contribute to many of the fatalities that occur 12 to 72 h or more after the injury As pointed out by Jennett, a majority of patients who remain in coma for more than 24 h after a head injury are found to have intracerebral hematomas Of these lesions, the most important are contusions of the surface of the brain beneath the point of impact (coup lesion) and the more extensive lacerations and contusions on the side opposite the site of impact (contrecoup lesion), as shown in Fig 35-4 Blows to the front of the head produce mainly coup lesions, whereas blows to the back of the head cause mainly contrecoup lesions Blows to the side of the head produce either coup or contrecoup lesions or both Irrespective of the site of the impact, the common sites of cerebral contusions are in the frontal and temporal lobes, as illustrated in Figs 34-4 and 35-5 The inertia of the malleable brain which causes it to be ung against the side of the skull that was struck, to be pulled away from the contralateral side, and to be impelled against bony promontories within the cranial cavity explains these coup-contrecoup patterns As noted, the experimental studies of Ommaya and others indicate that the effects of linear acceleration of the head are much less signi cant than are those due to rotation Relative sparing of the occipital lobes in coup-contrecoup injury is explained by the smooth inner surface of the occipital bones and subadjacent tentorium as pointed out by Courville The contused cortex is diffusely swollen and hemorrhagic, most of the blood being found around parenchymal vessels On CT scanning, the contusions appear as edematous regions of cortex and subcortical white matter admixed with areas of increased density representing leaked blood (Fig 35-6) The bleeding points may coalesce and give the appearance of a clot in the cortex and immediately adjacent white matter The predilection of these lesions for the crowns of convolutions attests to their traumatic origin (being thrown against the overlying skull) and distinguishes them from cerebrovascular and other types of cerebral lesions In nearly all cases of severe head injury there is damage to the corpus callosum by impact with the falx; necrosis and hemor-.