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 Essentials of
Anesthesia
for
Neurotrauma
http://taylorandfrancis.com
 Essentials of
Anesthesia
for
Neurotrauma

Edited by
Hemanshu Prabhakar
Charu Mahajan
Indu Kapoor
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

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No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-89507-2 (Hardback)

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Library of Congress Cataloging‐in‐Publication Data

Names: Prabhakar, Hemanshu, editor. | Mahajan, Charu, editor. |
Kapoor, Indu, editor.
Title: Essentials of anesthesia for neurotrauma / [edited by] Hemanshu
Prabhakar, Charu Mahajan and Indu Kapoor.
Description: Boca Raton : Taylor & Francis, 2018. | Includes bibliographical
references and index.
Identifiers: LCCN 2017053033| ISBN 9781138895072 (hardback : alk. paper) |
ISBN 9781315166742 (ebook)
Subjects: | MESH: Trauma, Nervous System‐‐surgery | Anesthesia‐‐methods
Classification: LCC RD81 | NLM WL 140 | DDC 617.9/6‐‐dc23
LC record available at https://lccn.loc.gov/2017053033

Visit the Taylor & Francis website at

http://www.taylorandfrancis.com

and the CRC Press website at

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To our parents, teachers, and the greatest gifts my parents gave to me, with whom I share my childhood

memories, Kavita and Hemant.

Hemanshu Prabhakar

To our parents, teachers, and the greatest gifts my parents gave to me, with whom I share my childhood

memories, Shelly, Shruti, and Aman.

Charu Mahajan

To our parents, teachers, and the greatest gifts my parents gave to me, with whom I share my childhood

memories, Sunita, Poonam, and Tanzin.

Indu Kapoor
http://taylorandfrancis.com
Contents

Foreword xi
Preface xiii
Acknowledgments xv
Editors xvii
Contributors xix

PART I INTRODUCTION TO NEUROTRAUMA

1 Introduction 3
Indu Kapoor, Charu Mahajan, and Hemanshu Prabhakar

PART II NEUROANATOMY

2 Anatomy of neurotrauma 9
Vasudha Singhal and Sarabpreet Singh

PART III NEUROPHYSIOLOGY

3 Neurophysiology in neurotrauma 31
Dinu Chandran and Manpreet Kaur

PART IV PREANESTHETIC EVALUATION

4 Prehospital care 57
Maria J. Colomina, Maylin Koo, and José María Soto-Ejarque
5 Preanesthetic evaluation 67
Julia Martinez Ocón, Ana Ruiz Pardos, and Ricard Valero
6 Emergency room resuscitation 75
Marta Magaldi, Luis Reyes, Marina Vendrell, and Ricard Valero

vii
viii Contents

PART V NEUROSURGERY

7 Extradural hematoma 89
Emma Temple and Asha Nandakumar
8 Subdural hematoma 97
Shanali Thirunavukkarasu and Morfaizan Ahmad
9 Subarachnoid hemorrhage 107
Emily G.Y. Koo, Mandy H.M. Chu, Patricia K.Y. Kan, Eunice Y.L. Dai, and Matthew T.V. Chan
10 Diffuse axonal injury 117
Marco Echeverria
11 Cervical spine injury 131
Ferenc Rabai and Lauren Berkow
12 Thoracolumbar spine injury 147
Monica S. Tandon and Priyanka Khurana

PART VI NEUROMONITORING

13 Monitoring in neurotrauma 185

Frederick A. Zeiler and Marek Czosnyka

PART VII NEURORADIOLOGY

14 Neuroradiology in neurotrauma 215

Zakir Hajat

PART VIII NEUROINTENSIVE CARE

15 Sedation and analgesia 223

Paola Cristina Volpi, Barbara Cambiaghi, and Giuseppe Citerio
16 Nutrition and metabolic care 235
Swagata Tripathy
17 Role of antibiotics 243
Martina Ornaghi, Valentina Ormas, and Daniela Ferlicca
18 Mechanical ventilation and respiratory care 255
Bastia Luca, Magni Federico, Pozzi Matteo, and Giuseppe Citerio
19 Cardiovascular care 267
Jovany Cruz Navarro, Vibha Mahendra, and Andrew W. Kofke
20 Neurologic care 285
Maria Chiara Casadio, Paola Cristina Volpi, and Giuseppe Citerio
21 Electrolyte disturbances and endocrinal care 295
Raffaele Di Fenza and Giuseppe Citerio
22 Neuromuscular care 317
Ankur Khandelwal and Hemanshu Prabhakar
23 Systemic care—Renal, hematologic, gastrointestinal 325
Panumart Manatpon and Andrew W. Kofke
24 Post-traumatic cognitive dysfunction 341
Ashima Nehra, Manju Mohanty, and Shivani Sharma
25 Psychological care 349
Sara Laxe and Neus Fàbregas
 Contents ix

PART IX SPECIAL CONSIDERATIONS

26 Pediatric neurotrauma 363

Ankur Khandelwal and Hemanshu Prabhakar
27 Geriatric neurotrauma 379
Hossam El Beheiry
28 Pregnancy and neurotrauma 387
Alexandra Kisilevsky and Alana M. Flexman
29 Polytrauma 399
Mohamed Samy Abdel Raheem

PART X FLUIDS

30 Fluid management 421

Shumaila Hasan and Matthew A. Kirkman
31 Coagulopathy and blood transfusions 433
Lamia Nayeb and Matthew A. Kirkman

PART XI PAIN MANAGEMENT

32 Pain management 447

Athir Morad and Salia Farrokh

PART XII PALLIATIVE CARE

33 Health-related quality of life and palliative care issues in neurotrauma 463

Suparna Bharadwaj and Lashmi Venkatraghavan

PART XIII BRAIN DEATH AND ETHICAL ISSUES

34 Brain death and ethical issues 473

Chiara Robba and Basil Matta

PART XIV RECENT ADVANCES

35 Recent advances in anesthesia for neurotrauma 489

Haley Reis, Onat Akyol, Vadim Gospodarev, Cesar Reis, Gocke Yilmaz, Richard Applegate II,
Sheng Chen, and John Zhang

PART XV CLINICAL PROCEDURES

36 Fiber-optic intubation 503

Prasanna Udupi Bidkar and K. Narmadhalakshmi
37 Chest drain insertion 517
Richa Aggarwal
38 Bronchoalveolar lavage 527
Mohan Gurjar
x Contents

39 External ventricular drainage 531

Vasudha Singhal
40 Lumbar drain 539
Kiran Jangra
41 Cranial burr hole 553
Srilata Moningi
42 Percutaneous tracheostomy 563
Ankur Luthra
43 Immobilization of spine 573
Rajeeb K. Mishra
44 Nasogastric tube insertion 577
Zulfiqar Ali
45 Intraparenchymal ICP catheter insertion 581
Nidhi Gupta

PART XVI WEBLIOGRAPHY

46 Summary of Brain Trauma Foundation guidelines (2016) and scales and scores 593
Ankur Khandelwal

Index 601
Foreword
ESSENTIALS OF ANESTHESIA
FOR NEUROTRAUMA
Globally, neurotrauma represents one of the most
important causes of neurodisability. Despite the
likely increase in neurodegenerative and cerebro-
vascular disease over the decades to come, the
World Health Organization (WHO) estimates that
traumatic brain injury (TBI) and spinal cord injury
(SCI) will continue to be important drivers of dis-
ability and, hence, will represent important public
health targets. This is particularly the case in low-
and middle-income countries, where motor vehicle
use is increasing at a rate far greater than the
population’s rate, with a consequent escalation in
the burden of death and disability caused by
neurotrauma.
Optimization of outcome from neurotrauma not
only depends on definitive neurosurgical interven-
tions but also requires skillful and well-informed
anesthetic and critical care practice. Such practice
can facilitate surgery when required and optimize
the physiologic context for recovery from injury.
However, none of the interventions that we use
in this context are risk free, and both knowledge
and procedural expertise are required to ensure the
best balance between the benefits and risks of
individual interventions. Furthermore, these inter-
ventions need to be embedded in a clinical frame-
work that delivers appropriate and timely care.
Given this context, this textbook, edited by a
clinician with substantial expertise and experience
in this area, is a welcome development. The con-
tents of this textbook, which represent the output of
an expert group of international authors, will help
both trainees and specialists to make judgments
that maximize benefit and minimize risk, with the
result that we not only increase survival from
neurotrauma but also improve the quality of this
survival.
David K. Menon
Cambridge, UK
xi
http://taylorandfrancis.com
Preface
Neurotrauma is a preventable public health issue,
yet it can have devastating consequences amount-
ing to huge community and economic losses. The
timely, proficient anesthetic and surgical manage-
ment is impetus for improving the outcomes. Yet,
there has never been a dedicated book covering all
of the aspects of neurotrauma along with the
various complications in the past. This book is
simple to read and understand and highlights all of
the practical aspects of anesthesia for patients with
neurotrauma. This book aims to provide an over-
view of the basics of anesthesia for neurotrauma.
Its target audience are trainees and fellows in
neuroanesthesia and anesthesia, including physi-
cians associated with neurosurgical and allied
branches, such as neurology and neuroradiology. It
will be very helpful, especially to those medical
practitioners who are providing anesthesia for
neurotrauma cases but who have not been formally
trained in the subject.
The purpose of this book is to provide basic
information on anesthesia for neurotrauma and
to explain how the management of different
neurotrauma cases may differ, especially those
involving the head, spine, and/or polytrauma.
Straightforward issues, such as neurologic exami-
nation of such patients and understanding their CT
and MRI scans, have been discussed in a simple,
easy-to-understand manner. Starting with the
prehospital management and resuscitation of these
patients, the book covers perioperative manage-
ment in great detail, including their care. Special
considerations, such as pediatric, obstetric, and
geriatric patients suffering neurotrauma have been
dealt with separately. The less-often discussed
issues, such as palliative care and rehabilitation,
have also been included to make the readers aware
of their importance and necessity. Another high-
light is the clinical procedures section, which pro-
vides quick and easy access and can be quite helpful
for all practical purposes. Thus, this book provides
insight into all possible aspects of the anesthetic
management of neurotrauma patients. The authors
of this book are experts in their fields and we are
grateful to all of the contributors who have made
this work possible.
Hemanshu Prabhakar
Charu Mahajan
Indu Kapoor
xiii
http://taylorandfrancis.com
Acknowledgments

We wish to acknowledge the support of the Special thanks are due to the production team
administration of the All India Institute of Medical at CRC Press/Taylor & Francis: Shivangi, Mouli,
Sciences (AIIMS), New Delhi, India, for allowing us Ritesh, Rajani, and Sunaina.
to conduct this academic task.
We thank the faculty and staff of the Depart-
ment of Neuroanesthesiology and Critical Care at
AIIMS for their support.

xv
http://taylorandfrancis.com
Editors
Hemanshu Prabhakar is a Professor in the
Department of Neuroanesthesiology and Critical
Care at All India Institute of Medical Sciences
(AIIMS), New Delhi, India. He received his train-
ing in neuroanesthesia at the same institute.
Recently, he completed a PhD and now has the
honor of being the first PhD (in neuroanesthesia)
in India. He is the recipient of the AIIMS
Excellence Award for notable contributions in
academics. He has more than 250 publications to
his credit. He is a reviewer for various national
and international journals. He is also a review
author for the Cochrane Collaboration and has a
special interest in evidence-based practice in
neuroanesthesia. Dr. Prabhakar is a member of
various neuroanesthesia societies and is a past
secretary of the Indian Society of Neuroanesthesia
and Critical Care. He is an invited faculty
member of numerous conferences, is on the edi-
torial board of the Indian Journal of Palliative
Care, and is the executive editor of the Jour-
nal of Neuroanaesthesiology and Critical Care.
Dr. Prabhakar has written many book chapters in
his area of expertise. He is the editor of Complica-
tions in Neuroanesthesia (2016) and Essentials of
Neuroanesthesia (2017), which were published by
Elsevier. He is also the editor of the Manual of
Neuroanesthesia (2017), which has been published
by CRC Press/Taylor & Francis.
Charu Mahajan is an Assistant Professor in the
Department of Neuroanesthesiology and Critical
Care at AIIMS, New Delhi, India. After complet-
ing a MD in anesthesia, she was awarded a DM
in neuroanesthesia at AIIMS and later joined as a
faculty member. She has authored over 60
publications in various national and international
journals. She is a reviewer for the Cochrane Col-
laboration. She also co-edited the book, Manual of
Neuroanaesthesia (2017), which has been pub-
lished by CRC Press/Taylor & Francis. She has
authored chapters in many books and has received
numerous awards for scientific presentations.
Dr. Mahajan is a member of various scientific soci-
eties and is a reviewer for several reputable scien-
tific journals.
Indu Kapoor is an Assistant Professor in the
Department of Neuroanesthesiology and Critical
Care at AIIMS, New Delhi, India. She received
her training in neuroanesthesia at the same insti-
tute. She is the recipient of the Dr. T N JHA
Memorial Award in 2009, which was awarded by
the Indian Society of Anesthesiologists (ISA) in
Chennai. She has also received the SMT Chandra
and SH Narayan Wadhwani Memorial Award
for best outgoing postgraduate in anesthesia at
the University College of Medical Sciences, Delhi,
in 2010. She has over 35 publications in national
and international journals to her credit. She is also
a reviewer of national journals and a review author
for the Cochrane Collaboration. Dr. Kapoor has
a special interest in evidence-based practice in
neuroanesthesia. Additionally, she is a member of
various national societies and has been an invited
faculty member at various national conferences.
Dr. Kapoor has written numerous chapters for
various national and international books.
xvii
http://taylorandfrancis.com
Contributors

Mohamed Samy Abdel Raheem Lauren Berkow

Department of Anesthesiology and Intensive Department of Anesthesiology
Care Division of Neuroanesthesia
Asyut University Hospitals University of Florida College of Medicine
Asyut University School of Medicine Gainesville, Florida
Asyut, Egypt
Suparna Bharadwaj
Richa Aggarwal Department of Neuroanesthesia and
Division of Trauma Surgery and Critical Care Neurocritical Care
JPNA Trauma Centre National Institute of Mental Health and
AIIMS Neurosciences
New Delhi, India Bangalore, India

Morfaizan Ahmad Prasanna Udupi Bidkar

Department of Anesthesia Department of Anesthesiology and Critical Care
Sheffield Teaching Hospitals JIPMER
Sheffield, United Kingdom Puducherry, India

Gocke Yilmaz Barbara Cambiaghi

Department of Anesthesiology School of Medicine and Surgery
Bahcelievler State Hospital University of Milan–Bicocca
Istanbul, Turkey Milan, Italy

Onat Akyol Maria Chiara Casadio

Department of Anesthesiology School of Medicine and Surgery
University of Health Sciences, University of Milan–Bicocca
Istanbul Bagcilar Training and Research Hospital Milan, Italy
Istanbul, Turkey
Matthew T.V. Chan
Zulfiqar Ali Department of Anesthesia and Intensive Care
Division of Neuroanesthesiology The Chinese University of Hong Kong
and Neurocritical Care Hong Kong Special Administrative Region, China
Sheri Kashmir Institute of Medical Sciences Soura
Jammu and Kashmir, India Dinu Chandran
Department of Physiology
Richard Applegate II All India Institute of Medical Sciences
Department of Anesthesiology and Pain Medicine New Delhi, India
University of California
Davis, California

xix
xx Contributors

Sheng Chen Marco Echeverria

Department of Neurosurgery Department of Anesthesiology
Second Affiliated Hospital Clinical Research
School of Medicine Wexner Medical Center
Zhejiang University Ohio State University
Hangzhou, Zhejiang, China Columbos, Ohio

Mandy H.M. Chu Hossam El Beheiry

Department of Anesthesia Department of Anesthesia
Pamela Youde Nethersole Eastern Hospital University of Toronto
Chai Wan, Hong Kong Special Administrative Toronto, Ontario, Canada
Region, China and
Trillium Health Partners
Giuseppe Citerio Mississauga Hospital
School of Medicine and Surgery Mississauga, Ontario, Canada
University of Milan–Bicocca
Milan, Italy Neus Fàbregas
and Anesthesiology Department
Neurointensive Care Hospital Clínic de Barcelona
Department of Emergency and Intensive Care University of Barcelona
San Gerardo Hospital Barcelona, Spain
ASST Monza, Italy
Salia Farrokh
Maria J. Colomina Department of Pharmacy
Department of Anesthesiology, Reanimation The Johns Hopkins Hospital
and Pain Clinic Department of Anesthesiology and Critical Care
Hospital Universitari de Bellvitge–Hospitalet Medicine
Universitat de Barcelona The Johns Hopkins School of Medicine
Barcelona, Spain Baltimore, Maryland

Marek Czosnyka Magni Federico

Section of Brain Physics Department of Emergency and Intensive Care
Division of Neurosurgery San Gerardo Hospital
Addenbrooke’s Hospital ASST Monza, Italy
University of Cambridge
Cambridge, United Kingdom Daniela Ferlicca
and Department of Emergency and Intensive Care
Institute of Electronic Systems San Gerardo Hospital
Warsaw University of Technology ASST Monza, Italy
Warsaw, Poland
Alana M. Flexman
Eunice Y.L. Dai Department of Anesthesiology, Pharmacology
Department of Imaging and Interventional and Therapeutics
Radiology University of British Columbia
Prince of Wales Hospital Vancouver General Hospital
Hong Kong Special Administrative Region, China Vancouver, British Columbia, Canada

Raffaele Di Fenza
School of Medicine and Surgery
University of Milan–Bicocca
Milan, Italy
 Contributors xxi

Vadim Gospodarev Ankur Khandelwal

Department of Physiology and Pharmacology Department of Neuroanesthesiology and Critical
Loma Linda University School of Medicine Care
Loma Linda, California Neurosciences Centre
All India Institute of Medical Sciences
Nidhi Gupta New Delhi, India
Department of Neuroanesthesia
Indraprastha Apollo Hospital Priyanka Khurana
New Delhi, India GB Pant Institute of Post Graduate Medical
Education and Research
Mohan Gurjar New Delhi, India
Department of Critical Care Medicine
Sanjay Gandhi Postgraduate Institute Matthew A. Kirkman
of Medical Sciences The National Hospital for Neurology
Lucknow, India and Neurosurgery
UCL Hospitals NHS Foundation Trust
Zakir Hajat Queen Square, London, United Kingdom
Department of Anesthesia and Critical Care
Royal Hallamshire Hospital Alexandra Kisilevsky
Sheffield Teaching Hospitals NHS FT Department of Anesthesiology, Pharmacology
Sheffield, United Kingdom and Therapeutics
University of British Columbia
Shumaila Hasan Vancouver General Hospital
The Royal London Hospital Vancouver, British Columbia, Canada
Barts Health NHS Trust
London, United Kingdom Andrew W. Kofke
Department of Anesthesiology and Critical Care
Kiran Jangra and
Department of Anesthesia and Intensive Care Department of Neurosurgery
Postgraduate Institute of Medical Education University of Pennsylvania
and Research Philadelphia, Pennsylvania
Chandigarh, India
Emily G.Y. Koo
Patricia K.Y. Kan Department of Anesthesiology, Intensive Care
Department of Anesthesia and Intensive Care and Pain Medicine
Prince of Wales Hospital Tan Tock Seng Hospital
Hong Kong Special Administrative Region, China Singapore, Singapore

Indu Kapoor Maylin Koo

Department of Neuroanesthesiology Department of Anesthesiology, Reanimation
and Critical Care and Pain Clinic
Neurosciences Center Hospital Universitari de Bellvitge–Hospitalet
All India Institute of Medical Sciences Universitat de Barcelona
New Delhi, India Barcelona, Spain

Manpreet Kaur Sara Laxe

Department of Physiology Brain Injury Department
Vardhaman Mahavir Medical College Institut Guttmann
and Safdarjung Hospital Hospital for Neurorehabilitation
New Delhi, India Barcelona, Spain
xxii Contributors

Bastia Luca Manju Mohanty

School of Medicine and Surgery Department of Neurosurgery
University of Milan–Bicocca Post Graduate Institute of Medical Education
Monza, Italy and Research
Chandigarh, India
Ankur Luthra
Department of Anesthesia and Intensive Care Srilata Moningi
Postgraduate Institute of Medical Education Department of Anesthesia and Intensive Care
and Research Nizam’s Institute of Medical Sciences
Chandigarh, India Hyderabad, India

Marta Magaldi Athir Morad

Department of Anesthesiology
Hospital Clínic de Barcelona
University of Barcelona
Barcelona, Spain
Charu Mahajan
Department of Neuroanesthesiology
and Critical Care
Neurosciences Center
All India Institute of Medical Sciences
New Delhi, India
Vibha Mahendra
Department of Anesthesiology
Baylor College of Medicine
Houston, Texas
Panumart Manatpon
Division of Neurocritical Care
Department of Anesthesiology
University of Pennsylvania
Philadelphia, Pennsylvania
Basil Matta
Neurosciences Critical Care Unit
Addenbrooke’s Hospital
University of Cambridge
Cambridge, United Kingdom
Pozzi Matteo
Department of Emergency and Intensive Care
San Gerardo Hospital
ASST Monza, Italy
Rajeeb K. Mishra
Department of Neuroanesthesiology
and Critical Care
All India Institute of Medical Sciences
New Delhi, India
Division of Neurocritical Care
Department of Anesthesiology
and Critical Care Medicine
The Johns Hopkins School of Medicine
Baltimore, Maryland
Asha Nandakumar
Department of Anesthesia
Royal Hallamshire Hospital
Sheffield Teaching Hospitals
NHS Foundation Trust
Sheffield, United Kingdom
K. Narmadhalakshmi
Department of Anesthesiology
and Critical Care
JIPMER
Puducherry, India
Jovany Cruz Navarro
Department of Neurology, Division of
Neurocritical Care
Department of Anesthesiology and Critical Care
University of Pennsylvania
Philadelphia, Pennsylvania
Lamia Nayeb
London Postgraduate Medical and Dental
Education
London, United Kingdom
Ashima Nehra
Clinical Neuropsychology at Neurosciences Centre
and
Division of Clinical Psychology
Department of Psychiatry
All India Institute of Medical Sciences
New Delhi, India

Julia Martinez Ocón
Department of Anesthesiology
Hospital Clínic de Barcelona
University of Barcelona
Barcelona, Spain
Valentina Ormas
School of Medicine and Surgery
University of Milan–Bicocca
Milan, Italy
Martina Ornaghi
School of Medicine and Surgery
University of Milan–Bicocca
Milan, Italy
Ana Ruiz Pardos
Department of Anesthesiology
Hospital Clínic de Barcelona
University of Barcelona
Barcelona, Spain
Hemanshu Prabhakar
Department of Neuroanaesthesiology
and Critical Care
All India Institute of Medical Sciences
New Delhi, India
Ferenc Rabai
Department of Anesthesiology
Division of Neuroanesthesia
University of Florida
College of Medicine
Gainesville, Florida
Cesar Reis
Department of Physiology and Pharmacology
Loma Linda University School of Medicine
Loma Linda, California
Haley Reis
Department of Physiology and Pharmacology
Loma Linda University School of Medicine
Loma Linda, California
Luis Reyes
Department of Neurosurgery
Hospital Clínic de Barcelona
University of Barcelona
Barcelona, Spain
Contributors xxiii
Chiara Robba
Neurosciences Critical Care Unit
Addenbrooke’s Hospital
University of Cambridge
Cambridge, United Kingdom
Shivani Sharma
Department of Laboratory Medicine
Clinical Neuropsychology
Neurosciences Centre
All India Institute of Medical Sciences
New Delhi, India
Sarabpreet Singh
Department of Anaesthesia
Sheffield Teaching Hospitals
Sheffield, United Kingdom
Vasudha Singhal
Medanta
The Medicity
Gurgaon, India
José María Soto-Ejarque
Cap Territorial RSCC
Emergències Mèdiques–Departament de Salut
Generalitat de Catalunya, Spain
and
Serveid’Anestesiologia i Medicina Crítica
Hospital d’Igualada
and
University of Barcelona
Barcelona, Spain
Monica S. Tandon
G.B Pant Institute of Post Graduate Medical
Education and Research
New Delhi, India
Emma Temple
Department of Anesthesia
Royal Hallamshire Hospital
Sheffield Teaching Hospitals
NHS Foundation Trust
Sheffield, United Kingdom
Shanali Thirunavukkarasu
Department of Anesthesia
Sheffield Teaching Hospitals
Sheffield, United Kingdom
xxiv Contributors

Swagata Tripathy Paola Cristina Volpi

Department of Anesthesia and Intensive Care School of Medicine and Surgery
All India Institute of Medical Sciences University of Milan–Bicocca
Bhubaneswar, Odisha, India Milan, Italy

Ricard Valero Frederick A. Zeiler

Department of Anesthesiology Division of Anesthesia
Hospital Clínic de Barcelona Addenbrooke’s Hospital
University of Barcelona University of Cambridge
Barcelona, Spain Cambridge, United Kingdom
and
Marina Vendrell Section of Neurosurgery
Department of Anesthesiology Department of Surgery
Hospital Clínic de Barcelona and
University of Barcelona Clinician Investigator Program
Barcelona, Spain University of Manitoba
Winnipeg, Canada
Lashmi Venkatraghavan
University of Toronto John Zhang
and Department of Physiology and Pharmacology
Department of Anesthesia and Pain Medicine and
Toronto Western Hospital Department of Neurosurgery
Toronto, Ontario, Canada Loma Linda University School of Medicine
Loma Linda, California
 PART I
Introduction to neurotrauma

1 Introduction 3
Indu Kapoor, Charu Mahajan, and Hemanshu Prabhakar
http://taylorandfrancis.com

Introduction
INDU KAPOOR, CHARU MAHAJAN, AND HEMANSHU PRABHAKAR
Trauma continues to be a major cause of morbidity
and mortality in developed and developing coun-
tries worldwide. According to the Global Burden of
Disease study report (2010), 89% of trauma-related
deaths occur in low- and middle-income countries.
Nearly 6 million people die every year as a result of
trauma, accounting for 10% of the world’s deaths,
which is 32% more than deaths from infectious
diseases.1 Although almost all types of injuries have
declined in recent years, neurotrauma has not,
leading to major deficits, long-term morbidity, and
deaths. Traumatic brain injury (TBI) and spinal
cord injury (SCI) are the largest causes of death and
disability, causing suffering and financial difficulties
for the individual, his or her family, and society as a
whole. The incidence of neurotrauma ranges from
200 to 600 injuries per 100,000 people. However,
these data are scattered and the real incidences of
central nervous system (CNS) injury are underes-
timated considerably.2 The data from developed
countries indicate that approximately 7.7 million
people in Europe and 5.3 million people in the
United States are having TBI-related disabilities.
The major cause of CNS injuries in developed
countries is motor vehicle accidents, whereas
in developing countries, it is mainly motorcy-
clists, bicyclists, and pedestrians.3 Also, there are
differences in the age groups that are affected by
neurotrauma disability: the older population in
developed countries and the younger population in
developing countries.3 Common deficits that are
associated with TBI, including depression, aggres-
sive behavior, poor decision making, impulsivity,
1
and impaired attention have negative social con-
sequences for individuals and for society as a
whole.4 Similar to TBI, data on SCI are also limited.
In developed countries, the incidence of SCI is
estimated to be approximately 250,000 to 500,000
per year.5,6 However, because there is no SCI reg-
istry in developing countries, information on inci-
dence of SCI is lacking. The most common causes
of SCI globally are traffic accidents, falls, and
violence.7 As is the case with TBIs, most of the
research on SCI is conducted in developed coun-
tries; the research focuses on the basic science of the
disease’s biologic process, which helps to develop
treatment guidelines, as well as applying advanced
technology to nerve reconstruction, sophisticated
prostheses, and advanced rehabilitation.7
Approximately 85% to 90% of TBIs are mild and
are described as acute brain injuries, resulting from
motion and position of the head as a result of
external forces with loss of consciousness of fewer
than 30 minutes, post-traumatic amnesia of less
than 24 hours, and a Glasgow Coma Scale (GCS)
score of 13 to 15, observed at 30 minutes post injury
or upon examination by a healthcare professional.8
Recent research on brain injury has focused mainly
on evaluating patients with concussions (mild
TBIs). Only 1% of all patients with mild TBIs with a
GCS score of 13 to 15 will have data on head com-
puterized tomography (CT), which requires neu-
rosurgical intervention.9 In patients with a GCS
score of 15, only 5% will have findings of hemor-
rhage on head CT; while this percentage rises to 30%
in patients with a GCS score of 13. Moreover, a CT
3
4 Introduction
scan has very little ability to rule out the presence of
diffuse axonal injury (DAI) and causes unnecessary
exposure to radiation. Magnetic resonance imaging
(MRI) has more sensitivity to DAI; its availability is
limited. For this reason, there has been growing
interest in serum biomarkers as a diagnostic tool in
TBI. The most widely used biomarker is S100β.
Others include neuron-specific enolase, creatine
kinase isoenzyme, myelin basic protein, glial fibril-
lary acidic protein, fatty acid-binding proteins,
ubiquitin C-terminal hydrolase-L1, and alpha II-
spectrin breakdown products. The goal of managing
anesthesia in patients with TBI is to avoid secondary
brain injury by preventing hypotension, hypoxemia,
too much or too little carbon dioxide in the blood,
fever, hypoglycemia or hyperglycemia, and/or
increased intracranial pressure (ICP). The perioper-
ative period is very important in TBI management.
While it may make the patient more vulnerable to
new secondary injuries, which may contribute
negatively to outcomes, it is also an opportunity to
detect and correct undiagnosed preexisting sec-
ondary causes. It may also be a potential opportu-
nity to initiate interventions that may improve the
severity of TBI. While waiting for the results of
research that is focused specifically on intraopera-
tive and perioperative TBI management, clinical
management will continue to be based on physio-
logic development. A large number of patients with
spinal cord injury (SCI) require operative inter-
vention. It should be assumed that all patients with
multiple traumas have an SCI until proven other-
wise. The majority of SCI (55%) involves the
cervical spinal column and 15% involves the
thoracolumbar junction.10 When it comes to anes-
thetic management, the most important approach
in the treatment of spine trauma is a high proba-
bility for early detection and prevention of sec-
ondary injury through adequate oxygenation, blood
pressure support through volume replacement, and
immobilization. It is important to use different
strategies to minimize blood loss during surgery.
Multimodality neuromonitoring is sensitive and
specific enough to detect neurologic injury during
spine surgery and the anesthetic that is used has
an impact on the quality of the multimodality
neuromonitoring.
Currently, there is no definitive therapy;
neurotrauma patients are treated with a combina-
tion of pharmacotherapy, surgery, rehabilitation,
and managing post-trauma conditions, such as
post-traumatic stress and depression. However,
there are interventions that can effectively limit the
impact, which include primary prevention, early
management, and targeted early treatment. Evidence-
based guidelines and management protocols help to
guide care and are associated with better outcomes.
Researchers around the world are continually striv-
ing to discover the best possible treatment; however,
an effective treatment method is not yet available.
Researchers are constantly working on prevent-
ing neurotrauma and improving treatment. Target-
oriented treatment and prevention require a deep
understanding of incidence, causes of injury, treat-
ment approaches, and outcome results. The chap-
ters in this book address, in detail, a scientific and
evidence-based understanding of the conditions in its
various dimensions, controversies regarding diag-
nostic and therapeutic approaches, outcome and
impact of neurotrauma on an individual and rapidly
transforming societies, challenges and opportunities
in research, and recent advances and future trends to
practice.
REFERENCES
1. Norton R, Kobusingye O. Injuries. N Engl J
Med. 2013;368(18):1723-1730.
2. Reilly, P. The impact of neurotrauma on
society: An international perspective. Prog.
Brain Res. 2007;161:3-9.
3. Horton, R. GBD 2010: Understanding disease,
injury, and risk. Lancet. 2012;380(9859):2053-
2054.
4. Hofman K, Primack A, Keusch G, Hrynkow S.
Addressing the growing burden of trauma
and injury in low- and middle-income coun-
tries. Am J Public Health. 2005;95(1):13-17.
5. Furlan JC. Databases and registries on trau-
matic spinal cord injury in Canada. Can J
Neurol Sci. 2013;40(4):454-455.
6. National Spinal Cord Injury Statistical Center.
The 2013 Annual Statistical Report for the
Spinal Cord Injury Model Systems (University
of Alabama at Birmingham, 2013).
7. Rubiano AM, Carney N, Chesnut R, Puyana
JC. Global neurotrauma research challenges
and opportunities. Nature. 2015;527(7578):
193-197.
8. Carroll LJ, Cassidy JD, Peloso PM et al.
Prognosis for mild traumatic brain injury:
Another random document with
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to occur in many Platyhelminthes: (1) the larger longitudinal canals,
and (2) the capillary vessels, which commence with (3) the flame-
cells in the parenchyma of the body. The mode of distribution of
these parts is not, however, ascertained. The canals are delicate,
sinuous, apparently intracellular tubes, coursing close to the margin
of the body and sending offsets which suspend the canals to the
dorsal surface, where possibly openings may occur. In dilatations of
these vessels bunches of cilia, and occasionally flame-cells, are
found. Usually, however, flame-cells occur at the commencement or
during the course of the capillaries, which are straight, rarely
branching, tubes of exceeding tenuity, and appear (Lang) to be
outgrowths of the flame-cells, just as the duct is an outgrowth of a
gland-cell. In fact there is little doubt that the stellate flame-cells are
modified parenchymatous gland-cells, containing a lumen filled with
a fluid into which a number of cilia project and vibrate synchronously.
The cells excrete nitrogeneous waste substances, which are then
discharged into the capillaries, whence the cilia of the main vessels
drive them presumably to the exterior, though external openings of
the excretory system are not known. Traces of this system have
been observed in young Leptoplana (first by Schultze in 1854) and
also in Cestoplana.

Sensation.—A nervous sheath, with scattered ganglion cells,

everywhere underlies the musculature. It is exceedingly faintly
marked on the dorsal surface, but laterally and ventrally forms a
dense network with polygonal meshes. Thickenings of this sheath
give rise to lateral nerves, and also to a pair of stout longitudinal
nerves from which the internal organs are probably innervated. The
brain, hardly distinct in pelagic Polyclads, in most forms does not
differ greatly from that of Leptoplana (p. 13).

The sense organs of Polyclads have the form of tentacles, eyes,

otocysts (in Leptoplana otophora), and stiff tactile cilia. The solid
dorsal tentacles of Planoceridae contrast strongly with the folded or
pointed hollow processes of the Cotylea. The former (Fig. 8, A, T)
are muscular and very contractile, and are placed near the brain
some distance from the anterior end. The latter are outgrowths of the
front margin of the body, and are sometimes (Yungia) provided
superficially with olfactory pits and internally with eyes and intestinal
coeca.

The eyes which occur in Polyclads may be divided into (a) a pair of
cerebral groups overlying the brain; (b) those embedded in the
tentacles (tentacular group); and (c) the marginal eyes, which in
Anonymus occur all round the margin. A complex form is sometimes
assumed by the cerebral eyes of Pseudoceridae, resulting probably
from incomplete fission (Fig. 11). Leptoplana otophora was obtained
by Schmarda on the south coast of Ceylon. On each side of the
brain is a capsule containing two otoliths. This is the only known
case of the occurrence of these organs in Polyclads.

Reproduction.—Although Polyclads are able to repair the result of

injuries to a very considerable extent, they are not known to multiply
asexually. The two processes are intimately associated, but, though
probably all Turbellaria can regenerate certain lost parts, asexual
reproduction only occurs sporadically.

Fig. 11.—Double eye from the cerebral group of Pseudoceros

maximus. (After Lang.)

All known Polyclads are hermaphrodite. The male organs, scattered,

like the testes of Leptoplana, over the ventral surface, develop
earlier than the ovaries, though the periods of maturation overlap;
hence the possibility of self-fertilisation, though remote, is still worth
consideration. The genital apertures, through which, in the male,
spermatozoa, and in the female, ova, are emitted, are usually
situated as in Leptoplana (Figs. 2 and 5, ♂ and ♀). In Trigonoporus,
a genus once found at Naples, a secondary female aperture has
been discovered leading into the female genital canal[35]; and in
Anonymus, Polypostia, and Thysanozoon (Fig. 7, E, ♂) two or more
male pores and penes have been found. Anonymus has several
penes (Fig. 7, D, ♂) arranged radially round the body. Polypostia, a
remarkable form described by Bergendal,[36] belonging to the
Acotylea, possesses about twenty such structures ranged round the
female genital aperture. Lang, whose attention was attracted by
these singular facts, made the interesting discovery that
Thysanozoon uses its penes as weapons of offence rather than as
copulating organs, burying them in the skin of another Polyclad
(Yungia) that happened to cross its path, spermatozoa being of
course left in the wound. Lang further found that Prostheceraeus
albocinctus and Cryptocelis alba in this way implanted a
spermatophore in the skin of another individual of the same species,
and he suggested that from this point the spermatozoa wandered
through the tissues till they met with and fertilised the eggs. It is now
known that a similar process of "hypodermic impregnation" occurs
sporadically in several groups of animals.[37] Nevertheless, in some
Polyclads it is probable, and in Stylochus neapolitanus it is certain,
that normal copulation takes place. The sperm-masses are
transferred to a coecal diverticulum of the female genital canal, and
then by a delicate mechanism, of which we know only the effects,
one spermatozoon obtains entrance into one matured ovum, which
differs from the ova of most Turbellaria in that it contains in its own
protoplasm the yolk necessary for the nutrition of the embryo. In
other words, there are no special yolk-glands. After fertilisation, the
ovum in all Polyclads is coated with a shell formed by the shell-
gland, which also secretes a substance uniting the eggs together.
They are deposited on stones and shells, either in plate-like masses
or in spirals (like those of Nudibranchs). Cryptocelis alba lays
masses of an annular shape, with two ova in each shell, and buries
them in sand.

Development.[38]—The first stages in the embryology of Polyclads

appear to be very uniform. They result, in all Cotylea and in certain
Planoceridae, in the formation of a Müller's larva (Fig. 12) about a
couple of weeks after the eggs are laid. This larva (1-1.8 mm. long),
which is modified in the Planoceridae, is distinguished by the
presence of a ciliated band, running somewhat transversely round
the body, and usually produced into a dorsal, a ventral, and three
pairs of lateral processes. When swimming the body is placed as in
Fig. 12, and twists round rapidly about its longitudinal axis by means
of the strong locomotor cilia placed in transverse rows upon the
processes. The cilia of each row vibrate synchronously, and recall
the action of the swimming plates of a Ctenophore. It is noteworthy
that whereas Stylochus pilidium passes through a modified or,
according to some authors, a primitive larval stage, its near ally, S.
neapolitanus, develops directly. Most Acotylea indeed develop
directly, and their free-swimming young differ from Müller's larva
merely in the absence of the ciliated band and in the mode of
swimming.

Fig. 12.—Section through Müller's larva of Thysanozoon brocchii

(modified from Lang). The right half is seen from inside. × 150.
Semi-diagrammatic. br, Brain; dl, dorsal ciliated lobe; dr, salivary
gland-cells of pharynx; e, eye; ep, ciliated epidermis containing
rhabdites; mg, stomach or main-gut; mg1, unpaired gut branch
over the brain; mo, "mouth" of larva; n, n1, section of nerves; oe,
ectodermic pit forming oesophagus of larva; par, parenchyma
filling the space between the alimentary tract and the body wall;
ph, pharynx lying in the cavity of the peripharyngeal sheath, the
nuclei of which are visible; sl1, sl2, sl3, lateral ciliated lobes of the
right side; vl, ventral ciliated lobe.
 Fig. 13.—Diagrammatic transverse sections of a larval Polyclad at
different stages, to illustrate the development of the pharynx.
(After Lang.) A, Larva of the eighth day still within the shell. The
main-gut (mg) is still solid, the epidermis is slightly invaginated,
and a pair of muscular mesodermic thickenings (ms) are present.
B, Young pelagic larva. The epidermic invagination has deepened
and developed laterally. C, The lateral pouches have formed the
wall of the peripharyngeal sheath, enclosing the mesodermic,
muscular, thickening or pharyngeal fold (ph). (Compare Fig. 12.)
Towards the end of larval life, when the ciliated processes (sl, Fig.
12) have aborted, the stage D is reached. By the opening
outwards of the pharyngeal sheath (ph.sh) the two apertures gm,
or true mouth, and m, or external mouth, are formed, which
together correspond with the oesophageal opening of the younger
larva. (Compare the transverse section in Fig. 5.)

Polyclads possess an undoubted mesoderm, which gives rise to the

muscles, the pharyngeal fold, and the parenchyma. The ectoderm
forms the epidermis, in the cells of which the rhabdites (Fig. 12)
arise, apparently as so many condensed secretions. From the
ectoderm the brain arises as two pairs of ingrowths, which fuse
together, and from these the peripheral nervous system grows out.
Three pigmented ectoderm cells give rise, by division, to the eyes—
an unpaired cell (Fig. 12, e) to the cerebral group of eyes, and the
other two to the marginal and tentacular groups. The copulatory
organs apparently arise to a large extent as ingrowths from the
ectoderm, from which the accessory glands (prostates, shell-glands)
are also formed. The endoderm forms the lining of the main-gut and
its branches. The pharynx is developed as in Fig. 13, which shows
that the "mouth" of the young larva (C) does not correspond exactly
with that of the adult (D). The salivary glands arise from ectoderm
cells, which sink deeply into the parenchyma. The reproductive
organs (ovaries and testes) possibly arise by proliferation from the
gut-cells (Lang, v. Graff). The change from the larva to the adult is
gradual, the ciliary band being absorbed and the creeping mode of
life adopted.

Turbellaria. II. Tricladida.

The Triclads are most conveniently divided into three groups[39]: (i.)
Paludicola, the Planarians of ponds and streams; (ii.) the Maricola,
the Triclads of the sea; and (iii.) Terricola or Land Planarians. From
the Polyclads they differ in their mode of occurrence; in the
elongated form of their body and almost constant, mid-ventral
position of the mouth; in possessing a single external genital pore
(Monogopora); and in the production of a few, large, hard-shelled
eggs provided with food-yolk.

Occurrence of the Paludicola.—The Planarians of our ponds and

streams are the most familiar and accessible Turbellaria. Their
elongated, flattened bodies, and gliding movements, render them
conspicuous objects on the under surface of stones and on the
leaves of aquatic plants, where they live gregariously. The variable
Polycelis nigra (Fig. 14, H) is very abundant in stagnant water and
slowly-moving streams, whereas its ally, P. cornuta (Fig. 14, G),
distinguished by a pair of tentacles, is more local. Planaria
(Dendrocoelum) lactea (A), P. polychroa (I), P. torva, and P. punctata
are not infrequently found together, but the last is at once the largest
and rarest.
 Fig. 14.—Forms of Triclads, with the distinguishing specific characters
of certain British forms. A, Planaria lactea O. F. M., × 2; B,
Planaria alpina Dana, × 4 (after Kennel); C, Phagocata gracilis
Leidy (after Woodworth), × 6; C', the same with the pharynges
(ph) extruded; D, Gunda ulvae Oer., × 4; E, Planaria gonocephala
Dug. (after Schmidt), × 4; F, genitalia of Gunda ulvae (after
Wendt); G, head of Polycelis cornuta Schm.; H, head of Polycelis
nigra Ehr.; I, head of Planaria polychroa Schm. K to N show the
distinctive characters of the genital ducts in K, Polycelis nigra; L,
Planaria polychroa; M, Planaria alpina; N, Planaria torva Schultze
(after Iijima and v. Kennel). ga, Genital atrium; go, common
genital opening; mgr, "musculo-glandular organ"; mo, "mouth";
ovd, oviduct; pe, penis; ph, pharynx; pyr, pyriform organs of
unknown significance; sc, sucker; sp, spermatophore lying in (ut)
uterus; vd, vesicula seminalis. (All except C and E are found in
England.)

Planaria alpina (Fig. 14, B) is characteristic of cold mountain

streams, but occurs down to sea-level in England, the Isle of Man,
and Ireland, and from its abundance in spring water, probably enjoys
a wide distribution underground. In the Swiss Alps it has been found
at altitudes of over 6000 feet, at lower levels in the Rhone, and also
in the Lake of Geneva. This wide distribution may perhaps be
accounted for, partly, by its faculty for asexual reproduction in
summer, and also, by the production, later in the year, of hard-
shelled eggs which are laid loosely, not attached to stones or plants.
[40]But we have no really direct evidence of the means of dispersal
of this or of any of the foregoing species, although they all have a
wide distribution in Europe. Of extra-European forms the accounts
that exist are very fragmentary. The only indubitable diagnostic
character of a Triclad is the structure of its genital ducts, and this is
accurately known in only a few cases. Several species such as
Dicotylus pulvinar (Fig. 16, B), at present known only from Lake
Baikal,[41] and others (Planaria mrazekii, P. albissima) from
Bohemia,[42] will doubtless be found elsewhere when they are
carefully looked for. Phagocata gracilis is a remarkable North
American form, possessing several pharynges (Fig. 14, C and C'),
recalling the independent movement of the pharyngeal lobes of
Discocelis lichenoides (Fig. 9).[43]

Occurrence of the Maricola.—Little as we accurately know of the

distribution of the fresh-water Planariae, our knowledge of the
occurrence of the marine forms is still more limited. Gunda
(Procerodes) ulvae (Fig. 14, D) is the commonest European form,
occurring abundantly in the upper part of the littoral zone, on the
shores of the Baltic. G. segmentata from Messina has been carefully
described by Lang,[44] but these are almost the only species of
Maricola which can be accurately determined. They differ from the
Paludicola in the position of the "uterus" behind the genital pore and
in the absence of a "musculo-glandular organ" (Fig. 14, F). A special
interest attaches to the Bdellouridae, a family containing three
species, all parasitic on Limulus from the east coast of America.
These remarkable Triclads usually have a sucker at the hinder end
of the body, by which they attach themselves firmly to the cephalo-
thoracic appendages and to the gill-plates, upon which the eggs may
be found in considerable numbers. One species, Syncoelidium
pellucidum, possesses a pair of problematical organs in the hinder
part of the body, opening to the exterior ventro-laterally by a couple
of chitinous mouth-pieces, but having no connexion with the genital
ducts.[45]
Occurrence and Distribution of Land Planarians.—The
terricolous Triclads or Land Planarians are the most interesting
division of the group. Some forms, such as Bipalium kewense, attain
large dimensions, being usually 6 to 9 inches in length, and
specimens fully extended have measured 18 inches. Their bodies
are frequently banded or striped with brilliant colours. Geoplana
coerulea Mos. has a blue ventral surface and is olive green or dark
Prussian blue above. G. splendens Dendy, is marked dorsally by
three stripes of emerald green alternating with four dark brown
longitudinal bands. The mode of coloration, though somewhat
variable, is an important specific character. Its significance, however,
is not clearly understood. The colours may be a warning signal, as
some Geoplana at least are disagreeable to the taste of man and
some birds[46]; but since Land Planarians are largely nocturnal
animals, living by day under logs, banana leaves, and in other moist
and dark situations, this explanation is clearly insufficient. Two
Geoplana have been noticed by Mr. Dendy which seem to be
protectively coloured. G. triangulata var. australis occurs abundantly
in the beech forest in the South Island of New Zealand, and its
brown back and yellow or orange ventral surface match the leaves
around its haunts. G. gelatinosa again looks like a mere slimy patch
on the rotten bark where it is found. In arid districts, during the dry
season, Land Planarians burrow in the soil and form a cyst, in which
they lie coiled up, after the manner of earthworms.[47] The glutinous
investment of their delicate bodies forms a moist medium in which
the cilia covering the body (and especially the ventral surface) may
constantly and evenly vibrate, and by which they adhere firmly to
their prey. In some tropical Planarians, in addition to possessing
offensive properties, the mucus is so copious in amount and hardens
with such rapidity, that these Triclads may creep over bridges of it,
and may even be blown from one stem or branch of a plant to
another, hanging at the ends of their threads.[48]
 Fig. 15.—Some Land Planarians found in Europe. A, Bipalium
kewense Mos. × ⅓ (after Bergendal); B, Rhynchodemus terrestris
O. F. M., × 2; C, Geodesmus bilineatus Metsch., × 2½ (after
Metschnikoff). mr, Region of mouth; gp, region of genital pore.

In Europe there are only two or three indigenous Land Planarians, of

which Rhynchodemus terrestris O. F. M. (Fig. 15, B) is the most
widely distributed, and has been found in moist situations for the
most part wherever it has been carefully looked for. It measures
about ¾ inch in length, and is dark grey above, whitish below, and
bears a pair of eyes near the anterior extremity (Fig. 15, B). Bipalium
kewense (Fig. 15, A), which has been found in the forests of Upolu,
Samoa, by Mr. J. J. Lister, has been accidentally imported, from the
(unknown) districts where it is indigenous, with plants and soil to
various parts of the world—England, Germany, the Cape, and also to
Sydney, where it appears to have established itself. In these Bipalia
living in hothouses, the genitalia never appear to attain maturity, and
apparently multiple fission and subsequent reparation of the missing
parts is the only mode of reproduction. Geodesmus bilineatus (Fig.
15, C), which has occurred at Giessen, Würzburg, and Dresden,
has, in all probability, been introduced with ferns from the West or
East Indies. Microplana humicola, described by Vejdovsky from
dunghills in Bohemia, is doubtfully indigenous.

In marked contrast with the poverty of the temperate zones in Land

Planarians, is the abundance and great variety of this group in
Southern Asia, South America, and especially in Australasia, where
the rich Land Planarian fauna has been carefully investigated by
Spencer, Dendy, Fletcher, and others, in certain parts of Victoria,
New South Wales, and New Zealand.[49] About forty species of
Planarians have been discovered on the Australian continent, thirty-
five of which belong to the predominant genus Geoplana,
distinguished by the presence of numerous eyes along the border of
the simple anterior extremity. Of the remaining five, four belong to
the genus Rhynchodemus, with, lastly, the introduced Bipalium
kewense. The distribution of any one species, however, is so limited
that only three forms are common to the two former colonies; and
although some of the twenty known New Zealand Planarians (chiefly
species of Geoplana), are identical with Australian species, yet only
one, or possibly two, varieties of these species are Australian also.
In addition to their prevalence in Australasia, the Geoplanidae also
occur in South America, South Africa, Japan, and the East Indies.
The Bipaliidae are characteristic of the Oriental region, being found
in China, Borneo, Bengal, and Ceylon. The Rhynchodemidae are a
cosmopolitan family, occurring in Europe, North and South America,
the Cape of Good Hope, Ceylon, the East Indies, Australia
(particularly Lord Howe Island), and Samoa.[50]

Habits and Structure of Triclads.—The common Planaria

(Dendrocoelum) lactea, which usually progresses by ciliary action,
aided, it is said, by muscular contractions of the ventral surface,
performs, if alarmed, a series of rapid "looping" movements, by
affixing a sucker (Fig. 14, A, sc), placed on the under side of the
head, to the substratum, and pulling the posterior end close to this.
The sucker, discovered by Leydig, is even better developed in P.
punctata (Fig. 16, A), P. mrazekii, and P. cavatica, and is an efficient
adhering-organ which has probably been developed from a similar
but simpler structure found in a considerable number of both fresh-
water and marine Triclads (P. alpina, Fig. 16, E). Probably the sucker
of the Land Planarian Cotyloplana (D) is the same structure, but the
two suckers of Dicotylus (B) are at present unique. Planaria dioica,
found by Claparède on the coast of Normandy,[51] is covered with
minute adhesive papillae, similar to those of certain Rhabdocoelida
(e.g. Monotus, Fig. 19, D), enabling it to cling tightly to the Zostera,
and so to resist the loosening action of the waves.

Fig. 16.—Suckers of Triclads. A, Planaria punctata Pall.; a, dorsal

surface of head; b, ventral surface (freely moving) showing the
sucker; c, sucker contracted (after Hallez): B, ventral surface of
head of Dicotylus pulvinar Gr., from Lake Baikal (after Grube): C,
dorsal surface of Procotylea fluviatilis Gir. (after Girard): D, sucker
of Cotyloplana whiteleggei Sp. (after Spencer): E, ventral view of
head of Planaria alpina Dana (preserved specimen); hg, adhering
groove; m, thickened musculature forming the margin of the
sucker; sc, sucker; t, tentacles.

The movements of Land Planarians are somewhat peculiar. The

ventral surface of Bipalium has a median groove, into which the
ducts of numerous mucus-glands open. This is bordered by two
ridges clothed with long and powerful cilia, which perform the chief
part in propelling the animal, aided, according to Lehnert,[52] by
muscular waves which pass from the head, backwards, i.e. opposite
in direction to those by which a snail slides along. This observation,
however, needs confirmation. The whole body executes sinuous
movements, during which the crescentic head, lifted slightly above
the ground (Fig. 15, A), is constantly altering and regaining its
normal shape, somewhat as a Planaria lactea uses the lobes of its
head. Further examination shows that the margin of the head of
Bipalium is not only provided with eyes, but in addition, with ciliated,
(probably) olfactory pits. Such depressions, innervated directly from
the cerebral ganglia, have been found in sixteen species of
Geoplana, and in one or two species of Rhynchodemus.[53] Some
Land Planarians (a species of Rhynchodemus from Ceylon, and a
Dolichoplana from the Philippines) wriggle out of a box or the hand
with great speed (Moseley).

The skin of Triclads is full of minute rods or rhabdites, which are shot
out in great numbers when the animal is irritated, and doubtless
serve an offensive purpose. The Terricola possess two kinds of
these: (1) needle-like rods; and (2) in Bipalium kewense, flagellated
structures, bent into a V-form and with a slender thread attached to
one end (Shipley). In Geoplana coerulea these bent rods furnish the
blue colour of the ventral surface. The rhabdites arise in all Triclads
in cells below the basement-membrane, which they are said to
traverse in order to reach the epidermis, thus differing in origin, and
also in structure, from the rods of Polyclads.

Food.—Triclads are largely if not wholly carnivorous animals,

feeding upon Annelids, Crustacea, Insects, Insect-larvae, and
Molluscs. The mouth is usually mid-ventral or behind the middle of
the body, but in the anomalous Leimacopsis terricola Schm. from the
Andes[54] and in Dolichoplana it is near the anterior end. The
pharynx (Figs. 17, 18, ph) is cylindrical or bell-shaped, exceedingly
dilatable and abundantly supplied with glands and nervous tissue. It
opens into the three main intestinal branches, one of which runs in
the median plane forwards, the others backwards right and left,
enclosing a space in which the genital ducts lie (Figs. 14, A, 17). The
fresh-water Planarians prey upon Oligochaeta, Hydrophilidae
(aquatic beetles), and the commoner pond-snails. Bipalium kewense
pursues earthworms, seizes the upper surface of the anterior end by
the glutinous secretion of its ventral surface, and then proceeds to
envelop part or the whole of the worm within its pharynx, which is
stretched as a thin skin over the body of its struggling prey (Lehnert).
The tissues of the latter pass into the intestine of the Planarian, and
distend it greatly. After such a meal, which lasts from one to five
hours, a Bipalium may remain for three months without seeking food.
Geobia subterranea, a white eyeless form from Brazil, pursues
earthworms (Lumbricus corethrurus) in their burrows, and has been
seen by Fritz Müller sucking the blood out of a young worm.[55]
Geoplana typhlops, a Tasmanian species, is also blind, and pursues
worms, as does G. triangulata (Dendy). In Trinidad, von Kennel[56]
observed that land-snails (Subulinae) were the food of certain Land
Planarians, the name of which, however, he does not state. The
pharynx was employed to suck out the soft parts of the snail even
from the upper whorls of the shell.

Reproduction.—In Planaria lactea the numerous testes (Fig. 17, te)

are placed both above and below the alimentary canal throughout
the greater part of its course. The membrane of each gonad is
continued into a minute vas efferens, which unites with those of
neighbouring testes. Two vasa deferentia (v.d) arise thus on each
side, one from the posterior, the other from the anterior testes of the
body, and open into the vesiculae seminales (v.s), which may be
seen in the living animal as tortuous whitish tubes at the sides of the
pharynx (Fig. 14, A). These open into the penis (Figs. 14, A; 17, pe),
a large pyriform organ, the apex of which, when retracted, points
forwards, projecting into the penial cavity. When this apical portion is
evaginated and turned inside out, it is of considerable length, and is
able to pass into the long slender duct of the uterus (ut) of another
individual. The penial sheath (ps) is part of the genital atrium (gs),
which is developed as a pit from the skin, and invests the end of the
genital ducts, the mouth of the pit forming the common genital pore
(go), through which both male and female genital products are
emitted.

There are two ovaries (ov) placed far forwards, between the third
and fourth pairs of intestinal coeca. The oviducts (ovd) lie just over
the lateral nerves, and have a slightly tortuous course, at each
outward bend receiving the duct (yo) of a yolk-gland (yg), so that ova
and yolk are already associated when the oviducts open by a short
unpaired tube into the genital atrium. The yolk-glands develop
rapidly,[57] and when fully formed are massive glands occupying the
spaces between the intestinal branches and the testes which are
then aborting. The so-called uterus (ut), apparently at first a
diverticulum of the genital atrium, expands behind the pharynx into a
receptacle lined by long glandular columnar cells, which, however,
are not all of the same kind. The uterine duct opens into the atrium
just above the aperture of a problematical, eversible, "musculo-
glandular organ" (mgr).

Fig. 17.—Diagrammatic view of the structure of Planaria

(Dendrocoelum) lactea. × 7. The body has been cut across and a
portion removed. In the posterior half the alimentary tract of the
left side is removed and the uterus, penis, and muscular organ
sliced open horizontally. The nervous system is represented by
black, and the yolk-glands by dotted lines. br, Brain; ey, eye with
lens and optic nerve; go, external genital aperture for both male
and female products; gs, genital atrium; lg, paired lateral intestinal
branch; ln, longitudinal nerve; mg, unpaired anterior intestine, the
branches of which are cut off close to the main stem; mgr,
eversible "musculo-glandular organ"; nc, nerve-cells in the
pharynx; nn, lateral nerve-twigs; ns, nerve-sheath; ov, ovary; ovd,
oviduct; pe, the eversible penis, the corrugated inner white portion
 of which is the apex; ph, pharynx; phs, pharyngeal sheath; pr,
"prostate" or granule-gland (represented by dotted lines opening
into the penis); ps, penial sheath; te, testes; to, tactile lobe of the
head; ut, "uterus" opening into the genital atrium just above mgr;
vd, vasa deferentia; vs, vesicula seminalis; yg, yolk-glands; yo,
openings of the yolk-ducts into the oviducts.

Fertilisation appears to occur in the uterus, where ova, yolk, and

spermatozoa, or (in P. torva) spermatophores (Fig. 14, N, sp), are
found. The formation of the cocoon in Planaria lactea is probably
begun in the "uterus," but is undoubtedly completed in the genital
atrium. In P. polychroa, however, the stalked cocoon is formed wholly
in the "uterus." Thus we find two types of cocoons in different
species of the genus Planaria associated with two types of
reproductive organs (Hallez):—

I. Planariae in which the two oviducts open separately into the

posterior part of the duct of the uterus. A musculo-glandular organ is
absent. The cocoons are spherical and stalked. Examples—Planaria
polychroa (Fig. 14, L), P. albissima, P. gonocephala.

II. Planariae in which the two oviducts open by means of an unpaired

duct into the genital atrium. A musculo-glandular organ present
(Planaria torva (Fig. 14, N), P. mrazekii, P. lactea, P. cavatica), or
absent (P. alpina, Fig. 14, M). The cocoons are sessile.

The genitalia of the Maricola (Fig. 14, F) and Terricola do not differ
very much from those of Planaria. The uterus (greatly reduced in the
Land Planarians) lies behind the genital pore, and several ova,
together with much milky yolk, are enclosed in a capsule which is
formed in the genital atrium.

Asexual Reproduction.[58]—It has long been known that fresh-

water Planarians have not only great powers of repairing injuries, but
that they use this faculty in order to multiply by transverse fission.
Planaria alpina and Polycelis cornuta, in summer, separate off the
posterior part of the body, and this ultimately becomes an entire
individual. P. albissima, and especially P. subtentaculata, anticipate
matters so far, that before fission is complete, the new individual has
a head nearly fully formed. The new organs are largely regenerated
in both parent and young, apparently by the division and
specialisation of scattered embryonic cells in the parenchyma. The
asexual reproduction of Land Planarians is not fully proved, though it
is known that they repair injuries to the body completely, and that
Bipalium kewense is often found in hothouses, divided into
fragments which regenerate all the organs of the parent, but like the
latter, do not mature their sexual organs.

Fig. 18.—Semi-diagrammatic view of the excretory system of Planaria

lactea. (Partly after Chickoff.) can, Capillary network on both
dorsal and ventral surfaces; g.br, branches of the intestine; lg,
lateral branches of the digestive system; ln, longitudinal nerve; ph,
pharynx, with intermuscular capillary excretory network arising
from the point marked pht; tp, principal vessels of the excretory
system, the external opening of which is not certainly known; vs,
vesicula seminalis.

Excretion.—The excretory organs of Triclads consist of flame-cells,

canaliculi, and a pair of longitudinal canals, the external openings of
which, have not been satisfactorily ascertained. The flame-cells are
difficult to detect in Planaria lactea, and the latest observer, Chickoff,
[59] was unable to see them, although to him we are indebted for
figures of this system in P. lactea (Fig. 18) and P. alpina (P.
montana). In the latter, the flame-cells are distinct, and may open
directly into the two main canals or indirectly through unbranched
canaliculi. The pharynx possesses a special supply of excretory
tubules communicating with the main canals. A similar system has
been described and figured in Gunda segmentata by Lang.[60]
 Classification of Tricladida.

PALUDICOLA.
Family. Genus and British Species.
Planariidae Planaria lactea O. F. M., P. punctata Pall., P.
polychroa Schm., P. torva M. Sch., P. alpina
Dana.
Polycelis nigra Ehr., P. cornuta Schm.
Anocelis.
Oligocelis, Procotyla. (Doubtful genera.)
Sorocelis.
Dicotylus.

MARICOLA.
Procerodidae Procerodes (= Gunda) ulvae Oersted, P.
(= Gundidae). littoralis van Beneden.
Cercyra.
Uteriporus.
Bdellouridae Bdelloura.
Syncoelidium.

TERRICOLA.
Bipaliidae Bipalium kewense Moseley (introduced).
Geoplanidae Geoplana.
Geodesmus.
Rhynchodemidae Rhynchodemus terrestris O. F. M.

Belonging to Dolichoplana.
undetermined Polycladus.
Families Microplana.
Leimacopsis.

Turbellaria. III. Rhabdocoelida.

The Rhabdocoelida include a very heterogeneous assemblage of
usually minute Turbellaria, distinguished collectively from the
Polyclads and Triclads by the form of the digestive tract. This is a
simple or slightly lobed sac, except in the Bothrioplanidae, which in
this and many other points closely resemble the Triclads. It is to the
straight, rod-like nature of the alimentary canal that the name of the
group refers. The size and form of the body, and the structure of the
pharynx and genitalia, vary within wide limits.

The Rhabdocoelida are subdivided into three tribes:—

(1) Acoela, in which a sub-central mouth and pharynx are present,

but lead into the parenchyma of the body, not into an intestine with
proper walls. An excretory system has not hitherto been seen. Yolk-
glands are absent. An otolith underlies the brain. The Acoela are
marine.

(2) Rhabdocoela, which possess a complete alimentary tract

separated from the body-wall (except for a few suspensory strands)
by a space or body-cavity, filled with fluid. This space is sometimes
(Vortex viridis) lined by an endothelium of flattened parenchymatous
cells. There are two compact testes, which are enclosed (as are the
ovaries and yolk-glands) in a distinct membrane. An otolith is present
in some genera and species. Terrestrial, fresh-water, marine.

(3) Alloeocoela, in which the body-cavity is greatly reduced. Except

in the Bothrioplanidae, the gonads have no distinct membrane.
Testes numerous; yolk-glands present. Marine with a few exceptions.

Occurrence and Habits of the Rhabdocoelida.—The Acoela are

usually minute, active Turbellaria abounding amongst weeds
throughout the lower half of the Littoral, and the whole of the
Laminarian zone, but are most plentiful in the pools exposed during
spring-tides on our coasts, especially on the shores of Devonshire.
The species of Haplodiscus, however, and Convoluta henseni are
modified pelagic forms found in the Atlantic Ocean.[61] Convoluta
paradoxa (Fig. 19, B) is the commonest British species. It is from 1
to 9 mm. in length, and of a brown colour, marked above by one or
more transverse white bars. The brown colour is due to a symbiotic
alga, the nature of which has not been thoroughly investigated. In an
allied species, however (C. roscoffensis), from the coast of Brittany,
the alga, which is here green, has been carefully examined by
Professor Haberlandt,[62] and it appears from his researches that the
algae form a special assimilating tissue, enabling the Convoluta to
live after the fashion of a green plant. At Roscoff, these elongated
green Convoluta live gregariously in the sandy tide-pools, fully
exposed to the sun's rays, and have the appearance of a mass of
weed floating at the surface of the water. Access to the atmosphere
and to sunlight are necessary in order to enable the assimilating
tissue to form the carbohydrates, upon which this form lives
exclusively. Not only has the alga itself undergone such profound
changes (loss of membrane, inability to live independently after the
death of the host) as to disguise its true nature (a tissue-cell derived
from algal ancestors), but the Convoluta has also undergone
concomitant changes, in form, in the loss of a carnivorous habit, and
in the development of marked heliotropic movements, thus adapting
itself to an holophytic or plant-like mode of nutrition. Nevertheless
the Acoela, as a group, are carnivorous, feeding upon Diatoms,
Copepoda, and small Rhabdocoela, the absence of a digestive tract
indeed being probably more apparent than real.[63]

The Rhabdocoela live under varied conditions. One form,

Prorhynchus sphyrocephalus, has been found among plants far from
water in the neighbourhood of Leyden, by De Man.[64] With this
exception the group is purely aquatic, and though a few genera and
even individuals of the same species occur both in salt and fresh
water, whole sub-families and genera are either marine or
paludicolous. Among the latter, Mesostoma, Castrada, Vortex, and
Derostoma are common in brooks and ponds, especially at certain
times, often only for one month (May or June) in the year. Species of
Macrostoma, Stenostoma, and Microstoma are also abundant in