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to side but betray no evidence of seeing or recognizing even the closest members of their families They do not speak and are capable of only primitive postural or re ex withdrawal movements Jennett and Plum referred to this as the persistent vegetative state (see page 305) Fourteen percent of the patients in the Traumatic Coma Data Bank remained in this state Hemiplegia or quadriplegia with varying degrees of decerebrate or decorticate posturing is usually demonstrable Life is mercifully terminated after several months or years by some medical complication Our colleague R D Adams has examined the brains of 14 patients who remained in coma and in vegetative states from one to 14 years All showed extensive zones of necrosis and hemorrhage in the upper brainstem In generalizing about this category of head injury, ie, patients who are and have been comatose from the time of injury, the effects of contusion, hemorrhage, and brain swelling often become evident within 18 to 36 h after the injury and then may progress for several days If the patients survive this period, their chances of dying from complications of these effects such as increased intracranial pressure, herniations of the temporal lobe, subdural hemorrhage, hypoxia, and pneumonia are greatly reduced The mortality rate of those who reach the hospital in coma is about 20 percent, and most of the deaths occur in the rst 12 to 24 h as a result of direct injury to the brain in combination with other nonneurologic injuries Of those alive at 24 h, the overall mortality falls to 7 to 8 percent; after 48 h, only 1 to 2 percent succumb There is some evidence that transfer of such patients to an intensive care unit, where they can be monitored by personnel experienced in the handling of head injury, improves the chances for survival (see further on).

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This group is smaller than the other two but is of great importance because it includes a disproportionate number of patients who are in urgent need of surgical treatment The initial coma may have lasted only a few minutes or, exceptionally, there may have been none at all in which instance one might wrongly conclude that since there was no concussion, there is no possibility of traumatic hemorrhage or other type of brain injury Patients who display this sequence of events, referred to as talk and die by Marshall and associates, deteriorate because of the delayed expansion of a small subdural hematoma, worsening brain edema, or occasionally the late appearance of an epidural clot Among 34 such patients in the Traumatic Coma Data Bank, the majority showed substantial degrees of midline shift on the initial CT scan, re ecting the presence of early brain edema and contusion (Marshall et al) A similar condition of delayed intracerebral hematoma, discussed further on (Spatapoplexie), is a feature of a more severe initial head injury that engenders coma from the onset

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SPECIFIC TRAUMATIC CRANIAL LESIONS (Table 35-2)

The following conditions must be considered in all cases of these delayed types but occur as often with serious initial injury

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As a rule, this arises with a temporal or parietal fracture and laceration of the middle meningeal artery or vein Less often, there is a tear in a dural venous sinus The injury, even when it fractures the skull, may not have produced coma initially, or it may be part

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Storage indexes are fairly simple in concept, as shown in Figure 3-4 When a table is accessed as part of a Smart Scan query, the Exadata Storage Server Software tracks the data in 1MB storage regions For each storage region, Exadata tracks the high and low values for many of the columns stored in the region The storage index is an in-memory collection of these statistics for all storage regions When a Smart Scan query hits the Exadata Storage Server, the values in the storage index may be used to eliminate storage regions from consideration in the query, based on predicate evaluation or the use of a Bloom filter for joins, as with standard Smart Scan processing Storage indexes are not enabled for National Language Support (NLS) columns or columns containing large objects If an operation writes to a storage region and changes values for a column being tracked in the storage

The problems created by acute and chronic subdural hematomas are so different that they must be discussed separately In acute subdural hematoma, which may be unilateral or bilateral, there may be a brief lucid interval between the blow to the head and the advent of coma Or, more often, the patient is comatose from the time of the injury and the coma deepens progressively Frequently the acute subdural hematoma is combined with epidural hemorrhage, cerebral contusion, or laceration The clinical effects of these several lesions are dif cult to distinguish; there are some patients in whom it is impossible to state before operation whether the clot is epidural or subdural in location Subdural clots more than 5 mm thick can be accurately visualized by the CT scan in more than 90 percent of cases (Fig 35-9) A large acute clot causes a pineal shift as well as marked compression of one lateral ventricle; but if the clots are bilateral, there may be no shift and the ventricles appear symmetrical Acute, rapidly evolving subdural hematomas are due to tearing of bridging veins, and symptoms are caused by compression of the brain by an expanding clot of fresh blood Unlike epidural arterial hemorrhage, which is steadily progressive, venous bleeding is usually arrested by the rising intracranial pressure Exceptionally, the subdural hematoma forms in the posterior fossa and gives rise to headache, vomiting, pupillary inequality, dysphagia, cranial nerve palsies, and, rarely, stiff neck and ataxia of the trunk and gait if the patient is well enough to be tested for these functions Because of their apposition to bone or their axial orientation along the tentorial dura, posterior fossa clots are more likely than clots over the cerebral convexities to be missed in CT scans In chronic subdural hematoma, the traumatic etiology is often

Figure 35-8 Acute epidural hematoma; unenhanced CT scan showing a typical lens-shaped frontal epidural clot

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