Familiar Neurosurgical Problems *A paper given to the Bristol Medico-Chirurgical Society, 10th March 1965.

Mr. George Alexander spoke to this Society in 1957 about displacements of the brain, and brainstem compression, with haematoma following head injury. Admission of cases of head injury to the Neurosurgical Unit has been selective, and concerned very largely with urgent surgery for acute intracranial haematoma. This may be the classical extradural haematoma from a middle meningeal vessel, or it may be subdural) with or without brain laceration; it may be entirely intracerebral, or a combination these conditions. It is not possible to distinguish between them on clinical groundsThe classical picture of a "lucid interval" after head injury, with headache, fa' creasing impairment of consciousness, hemiparesis on the side opposite to injury, an** dilating pupil on the injured side, is well known. It is dangerous to await the develop' ment of a full-blown classical syndrome. We must consider for admission withou* delay any patient believed to be deteriorating after head injury, even if but slightly' Many patients are urgently transferred because of suspected slight increase of drowsi' ness, or diminished responsiveness without any "lucid" or even "semi-lucid" intervalFive-eighths of these acute cases were admitted with twenty-four hours of injury during the period of a recent survey (Phillips and Azariah, 1965). Haematomas were found outside and inside the dura in equal numbers. Mortality was as low as any recorded elsewhere, being 15-6 per cent in uncomplicated extradural haematom3' As might be expected it was heavier with bleeding under the dura, where actual braijj laceration was present in many cases. Even then just over half survived. Nearly al' patients with extradural haematoma can be expected to make an excellent recovery-^ after all this condition does not itself damage the brain, provided it is treated promptly* and before fatal brain-stem compression has occurred. More surprising was the high proportion of good recoveries in cases of intradural haemorrhage where actual brain laceration may have been present with, incidentally' an increased liability to epilepsy. The differing prognosis in these conditions is reflected in a study of mortality ot patients in whom one or both pupils had become dilated and fixed either at the referring hospital or by the time of arrival at the Neurosurgical Centre. Over halt such patients survived when extradural haematoma was found at operation, but almost