2 P H Y S I O T H E R A P Y D E C E M B E R 19?? THE SURGERY OF BRAIN DAMAGE* J. C. D E V IL L IE R S * M .D ., F.R .C.S. (Eng. & E din.) ’n Oorsig van chirurge in breinskade w ord gegee. V o o rko m en d e en palliatiewe chirurgie w ord kortliks be- spreek. Chirurgie in spastisiteit sluil in neurektom ie, risotom e en longitudinale m ielotom ie en die voor- en nadele word bespreek. Serebellere dentatotom ie en ander chirurgie vir abnorm ale bewegings dateer van 1890 en w ord nog vandag bebruik. Chirurgie in die basale ganglia area w ord in uitsonderlike' gevalle aangedui. Ten laaste w ord chirurgie vir epilepsie en verhoogde intrakraniale d ru k bespreek. In th e central nervous system, th ere is no regenera­ tio n o f neurones w hich have b een irreversibly dam aged so th a t th e ir fu n ctio n has to be taken over, if a t all possible, by o th er neurones. Such fu nction al take-over m ay be im possible w here h ig h ly specialised cells, such as those concerned w ith vision, have been lost. W hat little evidence th ere is o f axonal sprouting a fte r in ­ jury, does n o t as yet apply to m an and the effects m ay be as m uch deleterious as beneficial. I t th erefo re stands to reason th a t prevention m ust be o u r forem ost concern at all times, as m any form s o f b ra in dam age are alm ost entirely preventable, fo r exam ple b irth injury and head injuries resulting from ro ad crashes. P RE V EN T IVE SU R G ER Y A ll space dem anding lesions such as in tracran ial haem atom as, abscesses, cysts and tum ours, lead to b ra in dam age by v irtu e o f pressure and should th erefo re be treated prom ptly. Prolonged raised in tracran ial pressure m ay cause secondary shifts of th e b rain p roducing com ­ pression o f the b ra in stem o r vascular occlusion w ith resu ltan t in farctio n w hich can be prevented by early rem oval o f the causative lesion. T h is is the underlying basis o f the neu ro su rg eo n ’s sense of urgency in dealing w ith these problem s. H e is only too p ainfully aw are o f th e disastrous effects o f delay. T ra n sie n t neurological episodes suggestive of carotid o r vertebral flow im p airm en t should lead to full in ­ vestigations to exclude the presence o f a treatab le lesion, such as a carotid a rte ry stenosis o r subclavian steal syndrom e. Once a p a tie n t has tran sien t ischaem ic attacks, there is a risk o f over 50% o f a com pleted stroke developing w ithin 18 m onths. Surgery fo r re­ m oval o f the source o f em boli and relief o f a m echani­ cal stenosis w ith resto ratio n o f adequate cerebral blood- flow, is reasonably sim ple and safe. Sim ilarly, the treatm en t o f in tracran ial aneurysm s and arterio v en o u s m a 'fn rm a tin rs H r ^ t a ;n ''f 1 r" 'u r e o f th e dam age already done, b u t to prevent rebleeding and fu rth e r dam age w hich m ay be fatal. E very person involved in th e m anagem ent o f u n ­ conscious patients, should at all tim es be concerned w ith the p a tie n t’s resp irato ry function so th a t adequate oxygenation o f th e blood reaching the b rain is en­ sured. C erebral hypoxia is p ro b ab ly the most frequent yet, m ost easily preventable cause o f brain damage. * H elen and M o rris M a’ierb creer P rofessor o f N e u ro ­ surgery, U n iv ersity of C ape T ow n and G ro o te Schuur H ospital. t A dapted from a paper delivered at a postgraduate course on “E a rly T reatm en t o f the H ead Injured P a tie n t” held a t the U n iv ersity o f C ape Tow n, lu ly 1976. M anagem ent o f th e secondary effects o f b ra in datnae m ay be p rim a rily m edical, as in the treatm en t o f spastj city and epilepsy, or, it m ay be surgical in w hich case it m ay fall w ith in the sphere o f the general surgeon the o rth o p aed ic surgeon and the neurosurgeon. This com m unication is concerned p articu larly w ith the neuro- surgical aspects o f treatm en t o f b ra in damage. PALLIATIVE SU R G ER Y A t th e outset it m ust be clearly stated th a t surgery cannot be the be-all and end-all of treatm en t o f anv p atien t w ith b rain dam age. S urgery is m erely a pan o f the to tal m anagem ent and m ust be integrated into th e individual treatm en t p rogram m e fo r th e patient M ost o f these o p eratio n s are destructive procedure" to a greater o r lesser extent and to advise surgery this n a tu re in a p a tie n t who alread y has gross l0i o f function, is a step n o t to be taken lightly. R em ark a b le results follow ing surgery are often due as m uch to th e personal a ttrib u te s o f the patient, his drive and com m itm ent, as to the surgical procedure. C hildren w ith b ra in dam age w ho have successful o p erations, usually have parents w ith the ability to guide th e ir disabled child thro u g h his th erap y to becom e a balanced personality despite physical handi­ caps and th e ir psychological concom itants. SU R G E R Y OF SPASTICITY S pasticity is a com m on result o f b rain and spinal cord dam age in adults and children. I t is a release effect fro m th e n o rm al to n ic in h ib ito ry influence on cells w hich subserve som atic m o to r functions. If the basic pathology cannot be affected by treatm ent, therapy is directed a t the final com m on pathw ay subserving m uscle tone. It is well know n how spasticity can h am p er a p a tie n t’s progress and how relief of spasticity by physiotherapeutic, m edical o r surgical means, can a t tim es restore a p a tie n t to activities w hich before w ould have been th o u g h t im possible. Non-surgical means o f alleviating spasticity, should be given an ade­ q u ate tria l before resorting to surgery. T h ere is no p o in t in adopting a die-hard attitu d e to som e method o f treatm en t and stretching th e p a tie n t on the rack ® th a t p articu lar m ethod, w aiting fo r a m iracle. If tl. p atien t is progressively getting w orse, denying him the benefit o f ad eq u ate surgery is as foolish as surgical overenthusiasm . T h e aim s in treatm en t o f spasticity a re :— 1. T o relieve spasticity, and 2. T o retain, if n o t im prove, m otor, sensory or sphincter function. T h e final n eural pathw ay fo r spasticity traverses the afferent fibres, the interneurones a nd efferent neurones at any p articu lar spinal segment. C hem ical o r surgical treatm en t is directed a t in te rru p tio n o f afferent, inter­ neuronal o r efferent pathw ays. T reatm en t by tenotomy o r tendon lengthening deals w ith the m echanical effects of spasticity. N EU RE C TO M Y This m ay be perform ed either by chemical or surgical m eans and usually in terru p ts efferent and afferent pathw ays to a muscle. Chemical Neurcctomy Local injection of phenol o r alcohol to interrupt R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pESEM BER 1977 F I S I O T E R A P I E 3 , nCtion in a nerve has a well-defined place in treating oa.sticity- T h e m uscle nerve points in question are Realized w ith stim ulating electrodes and then injected. !?he effects are, how ever, tran sien t (Cain et al, 1966); (laconibe et al, 1966). Phenol injection into spastic Muscles has been used p a rtic u la rly in m obilising th e \ L stic arm and hand in hem iplegic patients. T h e o b ­ turator nerves m a y be painted at open o p eratio n w ith phenol to relieve a d d u cto r spasm. gurgical Neurectomy The m ost freq u en t o p eratio n o f this type is o b ­ turator neurectom y fo r ad d u cto r spasm in the legs. There are a few basic criticism s o f neurectom y, the erst being th a t a p e rip h e ra l nerve is sectioned. I f it is a mixed nerve, th ere is sensory loss w ith its atten d an t risks. Irrev o cab le loss o f m uscle pow er occurs and muscle w asting and la te r contracture o f th e w asted muscle m ay follow . N eurectom y is n o t rejected en­ tirely, bu t plays a very clearly defined, if lim ited, p a rt in the m anagem ent o f spasticity. | R H IZ O T O M Y Surgical P o ste rio r R h izo to m y In 1898, S h errin g to n dem onstrated th a t decerebrate rigidity in experim ental anim als could be reduced by posterior n erv e-ro o t section. T h is effect is due to interruption o f afferent in p u t fro m m uscle spindles as well as o th er receptors. Foerster in 1908 applied this concept to m an by performing p o ste rio r ro o t section fo r spasticity so as to reduce the sensory in p u t w hich p ropagates spasticity. This involved section o f L. 2, 3, 4, 5 and S.l p o sterio r roots. T h e idea w as to leave some p o ste rio r ro o t sensory areas intact as it rap id ly becam e ap p aren t th a t the sensory loss w as a m ajo r deficit to som e of these patients w ho w ere im m obile on account o f th e ir p a ra ­ plegia. T h e beneficial effects, how ever, w ere o f short duration so th a t this o p e ra tio n fell into d isrepute fairly quickly. A nterior R h izo to m y was introduced b y M u nro in 1945. It does provide com plete relief o f flexor spasms but at the price of flaccid paralysis and can th erefore only be done below the level o f com plete cord lesions. In both these kinds o f rhizotom y, perm anent loss of neural fu n ctio n follow s in a person already neuro- logically disabled, and there is no h o p e o f any re ­ covery ever. P a tie n t selection has th erefo re to be ex- ^emc'l y careful. Selective A n te rio r R h izo to m y (M unro, 1952) Every second o r th ird fascicle o f the p a rtic u la r nerve- root concerned is divided so as to reduce m o to r o u t­ flow two- o r threefold. If too m any fascicles are divided, flaccid paralysis ensues. I t was a valuable m ethod but lacked p ro p er physiological control. Functional P o ste rio r R h izo to m y To overcom e the difficulties o f sensory loss and paralysis follow ing ro o t section, v ario u s types of selective p o sterio r ro o t section have been developed [Gros et al (1971), F ra io li & G u id etti (1977)]. Fascicles of roots are sectioned according to the effects produced by electrical stim ulation o r every fascicle is p artially sectioned, or, only 2 o r 3 fascicles in a p o sterio r root are left intact. T h is is usually done in the lu m b ar region because no t all fascicles a re divided o r divided com ­ pletely. T h ere is no extensive sensory loss an d no exten­ sive m o to r deficit. T his m ethod w orks on th e basis o f reduction in to tal input w ith o u t loss o f essential sensa­ tion, p a rtic u la rly proprioception. W h at is som ew hat surprising at first, is th a t there is relief o f spasticity a t levels higher th an th e a rea sectioned, p articu larly in children w ith cerebral palsy. E xperim ental justification fo r this has been p ro v id ed by K irk and D enny-B row n (1970). T h e re is in these children inadequate suppression of in p u t and b y re­ ducing the afferents at a few segm ents, lessens the to tal in p u t into the entire nervous system w hich can then fu n ctio n b etter even at h ig h er levels. C hem ical R h izo to m y M ah er (1957) treated a series o f p atien ts w ith in tra ­ thecal phenol fo r v arious indications and in this gro u p included a p a tie n t w ith severe flexor spasms; T h is m ethod was rapidly accepted an d developed p articu larly by N a th a n (1959, 1965). I t is a m ethod of treatm en t w ith considerable risks attached to it if not correctly carried out, but, if th e necessary p recau tio n s are taken and the injection o f the co rrect strength of phenol solution given under perfect radiological and clinical control, it becomes v irtu ally risk-free. I t can allow function to be recovered by rem oval o f disabling spasticity and it can even be given to am b u lan t p atien ts w ith o u t producing added n eurological deficit. I t w orks on the basis o f non-selective destruction o f nerve fibres in the p o sterio r nerve roots w hich consequently reduces the inflow o f im pulses into th e affected segments. T h e disadvantages o f the m ethod are, in th e first place, th e risks attached to it and the danger o f im p airin g bowel and bladder function. Several roots a re affected and undesirable m uscle w eakness m ay develop. In some patients th e in itial satisfactory effects m ay n o t be lasting* T o lim it the phenol effect to th e desired nerve roots, H a rris and Sim pson (1964) suggested lam inectom y fo r these patients and p ainting o f the nerve roots, in d i­ cated by electrical stim ulation, w ith glycerin and phenol. Even this procedure m ay be only tra rsie n tly effective and adds the b u rden o f a lam inectom y to p atien ts ra th e r severely disabled already. L O N G IT U D IN A L M Y E L O T O M Y Bischoff T ype 1 (1951) L ateral longitudinal m yelotom y is directed a t cutting longitudinally th e association fibres o f K o llik er ru n ­ ning betw een the a n te rio r and p o ste rio r horns an d in this w ay in terru p tin g som e o f the interneurones con­ cerned in m ain tain in g spasticity. L ateral longitudinal incisions are m ade in the spinal cord, along the line o f the dentate ligam ents fro m L .l to S .l. I f th e b lad d er is spastic, one side is cut dow n to S.5. Bischoff noted th a t this o p eratio n relieved spasticity b u t tended to in terfe re w ith the corticospinal tract an d decussating sensory fibres and th erefore m odified the operation. B ischoff Type 2 (1967) T his is a m edian p o sterio r longitudinal m yelotom y. A n incision is m ade in the m idline p o sterio rly to the level o f the central canal and lateral extensions are then m ade at rig h t angles to th e in itial incision in te r­ ru p tin g the connections betw een a n te rio r and p o ste rio r horns, but w ith o u t any dam age to th e corticospinal tracts. A considerable num ber of these o p eratio n s have been done and th e results have been very prom ising. W e have done th ree w ith ra th e r satisfactory results and no loss o f neurological function. All th ree patients w ere restored to activities w hich they had not had before. C E R E B E L L A R D E N T A T O T O M Y T h e effect o f cerebellar lesions on tone have been know n fo r a long tim e. C linical ap p licatio n of these R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 facts to p atien ts w ith ab n o rm alities of posture and tone, stem s fro m the w o rk o f N ashold and Slaughter (1969). T h e o p eratio n is stereotactically p erform ed and is based on the th eo retical assum ption th at in ­ creased o u tp u t along th e d e n tato -ru b ro th alam ic p ath ­ ways can be elim inated by p a rtia l dentate destruction. Im provem ent in spasticity is usually m ore m arked in p roxim al than distal m uscle groups. T re m o r m ay occur as a com plication o f the o p eration, p articu larly if the lesion is placed too f a r m edially. T h is o p eratio n has its greatest ap p licatio n in the treatm ent o f cere­ b ral palsy (D e K lerk, 1973). T h e n u m b er o f procedures av ailab le fo r th e tre a t­ m ent o f spasticity should indicate th at n o t one p ro ­ cedure is universally ap p licab le o r successful. I t has to be em phasized th at spasticity is a clinical concept w hich results fro m different patho-physiological m echa­ nisms varying fro m the site and natu re o f the lesion(s) in the nervous system. T H E SU R G ER Y OF A B N O R M A L M OVEM ENTS C horeo-athetosis is com m on in children as p a rt of the cerebral palsy syndrom e. T h ey do n o t only have d isturbing ab n o rm al m ovem ents but also ab n o rm alities o f posture. T he evolution o f the surgical treatm ent of these children is a long and fascinating one, beginning in 1890 when Sir V ic to r H orsley p a rtia lly excised the p refro n tal m o to r a rea in a child w ith severe hem i- athetosis w ith tem p o rary relief. H e suggested th a t the en tire m o to r area should have to be excised fo r perm anent effect on m ovem ent. In 1907 he rep o rted an o th e r child w ith hem iathetosis who had perm anent loss o f spasm odic m ovem ents w ith p a rtia l recovery of m ovem ent o f the left arm , after the in itial post­ o p erativ e paralysis but had p erm anent sensory loss on the left. T h is o p eratio n was m ore o r less forgotten except fo r sp o rad ic reports till 1932, when Bucy and B u chanan revived this w ork by subpial excision of the m o to r an d p rem o to r strips w ith some success and noted th a t the dystonic m ovem ents w ere less fa v o u r­ ably affected than the choreic (Bucy, 1951). A n y cortical o p eratio n left the p atien t not only w ith som e w eakness w hich could perhaps be regarded as a reasonable exchange b u t also w ith a very real risk of added p o st-trau m atic epilepsy. O ccasionally, how ever, p atien ts h ad better m o to r fu n ctio n afte r o p e ra tio n than before. A m ore lim ited attack on the so-called py ram id al tract was d irected at the co rtico sp in al m o to r tracts in the cerebral peduncles (W alker, 1949). This is a difficult o p eratio n as th e an ato m y does n o t con­ fo rm to the textbook description; even electro­ stim u latio n does not resolve the p ro b lem completely. T h e results are v ariab le an d n o t alw ays lasting, but it has retain ed a certain p o p u la rity in the hands o f some surgeons (M aspes & Pagni, 1964). SPIN AL TRACTOTOM Y Surgery d irected at the u p p e r cervical spine such as a n te rio r colum n section, has m et w ith little accep­ tance because o f th e m o to r an d sensory deficits in ­ curred when ad eq u ate relief o f choreo-athetosis was o b tain ed (Putnam , 1942). BASAL G A N G L IO N SU RG ER Y D irect surgical attack on the basal ganglia in the treatm ent o f dyskinesias, w as pio n eered by M eyers (1942). W ith th e developm ent o f stereotactic surgery, this m ethod becam e the accepted way o f dealing w ith m ovem ent disorders. T h e advantages are th a t a small lesion m ay be accurately placed in a nre d eterm ined target such as th e globus pallidus 0|! v entro-lateral nucleus of the thalam us w ith o u t daman ing the m o to r o r sensory tracts. By 1953, N arabayash' could re p o rt th a t ab o u t 50% o f the first group J ch oreo-athetotic p atien ts treated by chemopallidectom v were im proved an d in 1962, he rep o rted a 78% j J ’ provem ent in children w ith cerebral palsy an d move- m ent disorders. O nly children w ith o u t evidence o f spasticity and 0f n ear n orm al intellect, are suitable candidates f0r thalam otom y, w hich may aggravate spasticity. Most authors believe th a t dystonic and choreiform move- m ents are helped m ore than athetosis by thalamotomy In o u r experience w ith tw o patients, dystonia has rei sponded extrem ely well to venrolateral stereotactic thalam otom y. SU R G E R Y F O R SEIZURES A n a rea of cerebral tissue m ay b e destroyed by a w ide v ariety of pathological processes such as v ascu lr* occlusion, haem orrhage, inflam m atory lesions, m e c h a n * cal trau m a o r com pression by any expanding intra'. cranial mass. W hen this destroyed a rea heals, func­ tional n o rm ality does n o t necessarily retu rn and it m ay becom e an epileptogenic focus. I t should be noted th at the epileptic discharge does n o t o rig in ate in the lesion b u t in the b o rd e r zone betw een it and normal brain. U sually, such a focus lies in the cortex. Indications for Surgery A focal lesion producing partial o r generalized epilepsy such as a b ra in tum our, A -V m alform ation, cyst o r abscess, w hich can be rem oved safely an d with m inim al a d d itio n al surgical traum a. U sually, these patients are o p erated upo n because o f cerebral com­ pression ra th e r th an epilepsy, w hich is regarded as incidental an d sym ptom atic. E pilepsy w hich is uncontrollable m edically, and w hich originates fro m a localized focus th a t can be rem oved w ith o u t p roducing new neurological deficit. R em oval is best done by hem ispherectom y o r cortical scar excision. Hemispherectomy A small group o f children w ith infantile hemiplegia developed in tractab le epilepsy and later severe b&. havioural disturbances. T h e cause of the h em ipler'^ m ay vary. T he epilepsy m ay be partial o r generalize, but, usually the latter. B ehaviour disturbances are the m ost n o tab le fe a tu re o f this d iso rd er: tem p er tan­ trum s, violence, cruelty tow ards w eaker individuals, and lack of discipline are the outstanding features. There are gross E E G abnorm alities and plain X -rays show asym m etry o f the skull w hile a ir studies reveal marked u n ilateral v en tricu lar enlargem ent. F o r this kind o f problem , K ry n au w (1950) performed hem ispherectom y, rem oving the alm ost completely destroyed hem isphere. A large n u m b er of cases have been rep o rted (M cK issock 1953, W ilson 1970). D e s p i t e occasional late deaths due to h aem orrhagic complica­ tions, 2 o u t o f 3 o f th e survivors are seizure-free and a fu rth e r 14% m uch im proved. It is p ro b ab ly the most rad ical an d also the m ost successful o p e ra tio n fo r epi­ lepsy. I t does n o t ad d to the p a tie n t’s neurological deficit, w hich m ay indeed be lessened. T h e success w ith this pioneering o p eratio n , led to Penfield’s w ork on tem poral lobe epilepsy as a result o f w hich p atien ts w ith th is type o f epilepsy, are the ones m ost likely to benefit fro m surgery in the form o f tem p o ral lobectom y, provided th at the c o r r e c t indications are ad h ered to. D E C E M B E R 19?7P H Y S I O T H E R A P Y R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) pESEMBER 1977 F I S I O T E R A P I E of cortical scars^ s i o n Surgery for the cure o f this type o f epilepsy m ust • clude the m apping and rem oval o f th e en tire epi­ leptic area w ' , ^ o u t produ cin g any new n eu rological ^ T h ere is a very low m o rta lity in this type o f surgery „A the success ra te (total ab o litio n o r m ark ed reduc- f on in seizures) is ab o u t 5 0 % - 7 0 % , b u t th e failu re ate is virtually constant. F o r success, strict indications m u st be adhered t o . F ull and ad eq u ate m edical th erap y J!luSt have failed. C areful clinical an d lab o ra to ry in ­ v e s t i g a t i o n s m ust indicate th at th ere is a fo cal cortical le sio n present an d the area o f cortex involved m ust he dispensable w ith o u t adding to the p a tie n t’s n e u ro ­ logical deficit. (Rasm ussen, 1969). T h ere are o th er form s 0f surgery fo r epilepsy but th eir results are less p re ­ dictable and th e ir ap p licatio n has n o t becom e w ide­ spread. Surgery o f ab n o rm al b eh av io u r Some epileptics develop severe b e h a v io u r disorders auch as aggressiveness, extrem e restlessness, destruc­ tiveness and unpro v o k ed violent behaviour. W hen all medication fails, and the p a tie n t can only be insti­ tutionalised, certain form s o f surgery m ay give relief; the “sedative surgery” of Sano. S tereotactic am ygdalo- tomy, cingulotom y and postero-m edial hypothalam o- tomy have all been rep o rted as being beneficial b u t this is surgery w hich should no t be. lightly u n d ertak en on a c c o u n t of the m o ral and ethical considerations in ­ volved. t h e s u r g e r y o f r a i s e d i n t r a c r a n i a l P R E S S U R E B rain dam age m ay follow on elevated in tracran ial pressure as indicated earlier on. T h ere are tw o con­ ditions w hich deserve special m ention. T h e com m onest is the developm ent o f hydrocephalus afte r any fo rm of cerebral in ju ry and th e o th er is porencephaly. Hydro ccphalus Any lesion w hich leads to o b stru ctio n o f the o u t­ flow o f a lateral ventricle, th ird ventricle, aqueduct or fo u rth ventricle, o r even w hich leads to o b stru c­ tion o f the tem poral horn o f one lateral ventricle m ay 'cause a varying degree o f hydrocephalus p roxim al to S h e level o f obstruction. H y d ro cep h alu s produces ^secondary dam age due to stretching o f the p a ra v e n tri­ cular fibres and pressure. T h e sym ptom s o f raised intracranial pressure such as headache, vom iting an d papilloedem a, are to be w atched for. P erhaps m ore im portant th an these, although a little m o re subtle, are sym ptom s such as failu re o f concentration, intel­ lectual fall-off and loss o f recent m em ory. T h e latter ones m ay present them selves earliest of all to the therapist. T h e m edical atten d an t should take heed of these com plaints to prevent irre p a ra b le b ra in dam age by early surgery. Investigations often show a so-called occult hydrocephalus w here there are no sym ptom s of raised in tra c ra n ia l pressure b u t only those o f intellec­ tual im p airm en t, unsteadiness o f g a it and incontinence of urine. T h e re are m any m ethods av ailab le fo r tr e a t­ ing hydrocephalus pressure surgically, an d these can be very effective in restoring a p atien t to n o rm al life. Porencephalic Cysts T hese cerebral cavities o f varied aetiology occur particularly in children. T hey occur w ith in th e cerebral substance and com m unicate w ith the C SF pathw ays. Such com m unications may becom e sm aller o r blocked off and as fluid is being p u m p ed into them w ith o u t any outflow, they becom e secondarily space dem anding. T hey need early m anagem ent to p rev en t fu rth e r dam age to the b rain w hich has already suffered con- considerable injury. CONCLUSION A w ide range o f clinical conditions and a large n u m b er of surgical procedures have been m entioned. T hey m ay seem confusing, b u t it does indicate the in adequate state o f o u r know ledge and th erap y o f the b ra in dam aged individual. 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