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of a devastating craniocerebral injury A typical example is that of a child who has fallen from a bicycle or swing or has suffered some other hard blow to the head and was unconscious only momentarily A few hours or a day later (exceptionally, with venous bleeding the interval may be several days or a week), headache of increasing severity develops, with vomiting, drowsiness, confusion, aphasia, seizures (which may be one-sided), hemiparesis with slightly increased tendon re exes, and a Babinski sign As coma develops, the hemiparesis may give way to bilateral spasticity of the limbs and Babinski signs The pulse is often slow (below 60 beats per minute) and bounding, with a concomitant rise in systolic blood pressure (Cushing effect) The pupil may dilate on the side of the hematoma Physicians need not be reminded that lumbar puncture is contraindicated in this setting, particularly now that CT and MRI are available Death, which is almost invariable if the clot is not removed surgically, comes at the end of a comatose period and is due to respiratory arrest The visualization of a fracture line across the groove of the middle meningeal artery and knowledge of which side of the head was struck (the clot is usually on that side) are of aid in diagnosis and lateralization of the lesion However, meningeal vessels may occasionally be torn without fracture The CT scan reveals a lens-shaped clot with a smooth inner margin (Fig 35-8) The surgical procedure consists of placement of burr holes in an emergency situation or, preferably, a craniotomy, drainage of the hematoma, and identi cation and ligation of the bleeding vessel The operative results are excellent except in cases with extended fractures and laceration of the dural venous sinuses, in which the epidural hematoma may be bilateral rather than unilateral If coma, bilateral Babinski signs, spasticity, or decerebrate rigidity supervene before operation, it usually means that displacement of central structures and crushing of the midbrain have already occurred; prognosis is then poor Small epidural hemorrhages, followed by serial CT scanning, will be seen to enlarge gradually for a week or two and then be absorbed There is always controversy about removing these in a patient who has no symp-.

Figure 35-9 Acute subdural hematoma over the right convexity, with substantial mass effect (displacement) of brain tissue but little edema

FIGURE 3-4

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type of message usually occurs after the BIOS has successfully found the Master Boot Record (MBR) and locates the boot sector of the system partition You will generally only see this message if you are using a DOS-formatted disk, not on an NTFS file system To fix this error in Windows 9x, boot from a startup floppy disk and SYS the boot drive A good copy of the IOSYS and MSDOSSYS files on the boot disk will be placed on the boot drive You will also need to copy over the COMMANDCOM file if it s missing from the drive you want to boot The Bad or missing command interpreter message occurs after the operating system has been loaded and the command processor is attempting to load This is the COMMANDCOM program that resides on the system partition in the case of a DOS system You will not see this type of error message on a Windows NT/ 2000/XP system However, if you receive the BOOT: Couldn t find NTLDR message on Windows NT, 2000, or XP, use the startup disks or CD with the Recovery Console to boot the computer and select to perform a repair Use the emergency repair process to replace the NTLDR file on the boot drive This error can also occur if a virus attacks the MBR First, you should run an antivirus application to be sure you don t have a boot sector virus If you don t, it may be possible to replace the MBR To do so, boot from the Windows 9x startup disk and execute the following command:

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