Outcome of and prognostic factors for decompressive hemicraniectomy in malignant middle cerebral artery infarction.

Decompressive hemicraniectomy as an appropriate treatment for malignant middle cerebral artery (MCA) infarction is still a controversial issue. This study aimed to determine the survival rate and functional outcome, and factors associated with these, in patients with malignant MCA infarction. From January 2000 to December 2003, 60 patients with malignant MCA infarction were treated in our hospital. All patients in the study underwent a large ipsilateral craniectomy and duroplasty for decompression. The infarction territory was evaluated by either diffusion weighted magnetic resonance imaging or computed tomography. Clinical neurological presentation was evaluated using the Glasgow Coma Scale. Functional outcome was evaluated using the Barthel index (BI) and the Glasgow Outcome Scale (GOS) at follow-up 12 months later. Thirty-day mortality was 20% (12 patients) and 12-month mortality was 26.6%. The factors associated with higher mortality were age>or=60 years, involvement of more than one vascular territory, presence of signs indicating clinical herniation before surgery, and treatment more than 24 hours after ictus. The mean GOS score was 3.3+/-1.7. The mean Barthel index was 65.1+/-40.1. Twenty-nine (65.9%) patients had a favourable outcome (BI>or=60). The factors associated with favourable outcome were age<60 years and treatment within 24 hours of ictus, before clinical signs of herniation were noted. Decompressive hemicraniectomy should be performed in patients younger than 60 years within 24 hours of ictus before clinical signs of herniation develop. Age, timing of surgery and clinical signs of herniation are prognostic factors for mortality and functional outcome.

Outlook for the child with a cephalocele.

Specific information on the outcome for a child with a cephalocele can be difficult to find and interpret. To update outcome information for the child with a cephalocele, the investigators compared outcome of 34 infants from their institution with that of those in previously published series. For the infants from the investigators' institution, overall mortality was 29% and was confined to infants with posterior defects, which was consistent with other published series. Additional major congenital abnormalities were present in nearly half the infants, and these were an important factor in contributing to a poorer prognosis as well as whether the defect could be operatively reduced. Seizures and hydrocephalus were often secondary problems in those infants who did worse. In addressing outlook for the infant with the cephalocele, primary factors to be considered are operability and the presence of additional major abnormalities, both intracranial and extracranial.

Results of single burr hole drainage for acute subdural hematoma with non-reactive pupil.

AIM: To investigate the effects of emergency burr hole drainage for acute subdural hematoma (ASDH) with bilateral non-reactive pupils. MATERIAL AND METHODS: A retrospective study was conducted by reviewing medical records from 1998 to 2007. Patients meeting the following criteria were included: 1) head injury with unconsciousness (Glasgow Coma Scale score 8); 2) bilateral non-reactive pupils on arrival; 3) ASDH with disappearance of basal cistern on computed tomography (CT); and 4) performance of emergency single burr hole drainage. Subjects were divided into survival and non-survival groups. RESULTS: Pupil size on the small side was significantly smaller in the survival group than in the non-survival group. All pupils on the small side in the survival group were 4 mm. CONCLUSION: Emergency burr hole drainage should still be considered in patients with ASDH showing bilateral non-reactive pupils and one pupil 4 mm.

Frontoethmoidal meningoencephalocele: appraisal of 200 operated cases.

OBJECT: Frontoethmoidal mengingoencephaloceles (fMECs) are frequently observed in Cambodia, especially in poor families. The authors describe issues related to the surgical treatment of fMECs in Cambodia at the end of a humanitarian program that provided surgery free of charge to patients and their families. METHODS: The authors reviewed 257 cases of fMEC involving patients who presented to their institution, the Children's Surgical Center in Phnom Penh, between 2004 and 2009. They treated 200 of these patients surgically (108 males, 92 females; 89% younger than 18 years) using a "low-cost" management plan with no routine pre- or postoperative investigations. Initially, surgery was performed by visiting foreign surgeons who taught the procedures to resident surgeons. Patients were not charged for consultations or treatment and received at least 1 follow-up examination 6 months postoperatively. RESULTS: The nasoethmoidal type was the most frequent fMEC encountered (69%). Many patients had associated ophthalmological issues (46% of cases). Only 1 familial case was detected. Combined neurosurgical and facial procedures were successfully standardized and learned by surgeons initially unfamiliar with fMEC management. A neurosurgical approach avoided the need for a facial incision in 42 cases, improving cosmetic results. The most common postoperative issues were a temporary CSF leak (24 cases [12%]) and/or infection (28 cases [14%]). There were 3 deaths directly related to the operations. Cosmetic results were good in 145 cases, average in 27, poor in 7, and worse than preoperative appearance in 6 patients. Fifteen patients were lost to follow-up. The parents of 87% of the children were rice farmers. Questionnaire results confirmed that fMEC has important social and educational consequences for the affected children and that these consequences can be partially improved by fMEC correction. CONCLUSIONS: This experience in fMEC management demonstrates that local surgeons can treat these malformations with limited surgical materials and in a nonspecialized infrastructure after principles of treatment have been learned and if they are carefully respected. Surgery for fMEC can thus be more accessible to a larger number of patients in developing countries. Moreover, local treatment facilitates better postoperative and follow-up care.

Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review.

OBJECTIVES/HYPOTHESIS: Temporal bone meningoencephalic herniation is a rare condition with potentially dangerous complications. The aim of this study is to analyze the pathogenesis, clinical presentation, surgical treatment, and postoperative outcome of 133 cases of surgically confirmed temporal bone meningoencephalic herniations. A review of the literature is also presented. STUDY DESIGN: Retrospective case series (quaternary referral otology and skull base center). METHODS: This study is based on the analysis of the collected data of 133 cases of temporal bone meningoencephalic herniations surgically treated from 1984 to 2006. The follow-up ranged from 12 to 204 months with a mean of 38.4 months. RESULTS: Meningoencephalic herniations were divided into four etiologic groups: spontaneous (24.8%), secondary to chronic otitis media (21.8%), iatrogenic (45.9%), and posttraumatic (7.5%). Different surgical techniques were used for treatment: transmastoid approach (27.8%), middle cranial fossa approach (27.8%), combined technique (transmastoid plus minicraniotomy, 3%), and middle ear obliteration with blind sac closure of the external auditory canal (41.4%). CONCLUSIONS: Temporal bone meningoencephalic herniations are potentially life threatening, and surgery must take place expeditiously. The choice of the most appropriate surgical approach must be based on the localization and size of the herniated tissue, preoperative auditory function, the presence of active infection, intraoperative cerebrospinal fluid leak, and concomitant pathology.

Cranium bifidum in northern Nigeria.

At the Ahmadu Bello University Hospitals in northern Nigeria, 35 girls and 29 boys with cranium bifidum were registered between 1971 and 1985. Only 25% of the patients were brought to the hospital within 24 h of life; 57 had been delivered at home without the mothers having received formal prenatal care. The majority (69%) of the lesions occurred in the occipital region; 52 (81%) were encephaloceles while the others were cranial meningoceles. Resection and repair were performed in 35 patients by general surgeons who had no facilities for vertriculoperitoneal shunts in infants with hydrocephalus. Thirteen children died in the hospital, 3 moved away, and 34 were lost to follow-up at 1 month. Only 3 were seen up to 1 year. Improvement in the care of such patients is expected since a neurosurgical unit has now been established.

[Meningoencephalocele]. / Meningoencefalocele.

A total of 52 children with meningoencephalocele were operated during a 23 year period. The anomaly was located frontally in nine children, occipitally in 34 children and infratentorially in nine children. Because of progressive hydrocephalus, 18 children underwent shunt procedures shortly after the initial surgical correction. The prognosis was related to the localization and the content of the cell sac, and to additional congenital anomalies. Nine children died and five are severely disabled. For 38 children the result is good, with no major disabilities. In the case of children with meningoencephalocele the possibility of surgical correction should be considered shortly after birth.

Fatal lumbar puncture: fact versus fiction--an approach to a clinical dilemma.

Recent reports and commentaries have emphasized the alleged risk of cerebral herniation complicating lumbar puncture performed to diagnose acute bacterial meningitis. Instead, knowledge of facts relevant to the disease process can provide a rational and reassuring approach to management. All cases of purulent meningitis are associated with increased intracranial pressure, but herniation is a rare complication (5%). Despite suggestions to the contrary, cranial computed tomography (CT) is normal in most cases of purulent meningitis, including those with subsequent herniation. Additionally, CT may be associated with long-term radiation effects. An accurate clinical history combined with recognition of the early systemic and neurologic findings of bacterial meningitis will indicate a safe setting for performance of a diagnostic lumbar puncture with little likelihood of complicating herniation. In contrast, in patients in whom the disease process has progressed to the neurologic findings associated with impending cerebral herniation, a delay of the diagnostic procedure is indicated. In this latter circumstance, a different approach in management can be developed.

[Aspects of long-term management of children with myelomeningocele. Analysis of the last 10 years from the neuropediatric-neurosurgical viewpoint]. / Aspekte der Langzeitbetreuung von Kindern mit Myelomeningozele. Analyse der letzten 10 Jahre aus neuropädiatrisch-neurochirurgischer Sicht.

BACKGROUND: Both the use of a selective policy of treatment of newborns with myelomeningocele and the right time of back closure are still controversially discussed. We report our experiences in the long-term care of children with myelomeningocele. METHODS: 103 newborns with myelomeningocele (n = 94) and meningocele (n = 9) born 1980 to 1990 and cared for regularly at the Olgahospital's pediatric clinic were followed up from the neuropediatric-neurosurgical point of view. Postpartum we predominantly practised a selective policy of treatment. RESULTS: 15 of 21 children (71.4%) not operated on died during the first days or months of life, 6 (28.6%) survived. 70 were operated selectively, of which 9 (12.9%) died, 61 (87.1%) survived with mainly good result. There were no differences in the survival rate and frequency/type of postoperative complications with respect to the time of the back closure. 31 children with myelomeningocele (33%) had CNS anomalies other than the Arnold-Chiari-Malformation, mostly being a dys- or aplasia of the corpus callosum and a deformed ventricle system. These were diagnosed almost exclusively by CT or MRT scan. CONCLUSIONS: We still predominantly practised a selective policy of treatment of newborns with myelomeningocele with mainly good results.

Myelomeningocele newborn management: time for parental decision.

We retrospectively reviewed a process whereby parents were afforded additional time to decide the initial managements of their newborn with myelomeningocele. Of 110 newborn referrals, 52 (47%) had early surgery within the first 48 hours, 32 (29%) had delayed surgery between 3-7 days, 12 (11%) had late surgery from 7 days to 10 months, and 14 (13%) had no surgery, per parental request. There were no significant differences among the early, delayed or late surgery groups in mortality where 92%, 94% and 100% respectively were alive at 10 months, or the morbidity of worsening paralysis, ventriculitis or developmental delay. Our data suggest, therefore that there is no urgency or emergency for surgical intervention in the initial management of newborns with myelomeningocele. Rather, there is time to fully discuss issues with parents and obtain a better-informed consent for or against surgical management.

The child with a cephalocele: etiology, neuroimaging, and outcome.

We report a series of 46 children who were treated for one of the diverse forms of cranium bifidum during a period of 22 years. The purpose of the survey was to investigate pathogenetic factors involved in the development of cranial dysraphism and to analyze clinical and pathological factors that influence the patients' outcome. We also investigated the existence of associated intracranial anomalies, in a systematic way, using modern methods of neuroimaging, and related the findings to the patients' final results. The lesions were classified as encephalocele (n = 15), cranial meningocele (n = 3), atretic cephalocele (n = 26), cranium bifidum occultum (n = 1), and exencephaly (n = 1). There was an excess of the atretic form of cephaloceles in our series, a fact that probably reflects geographical variations described for cephaloceles in general. The location of the lesions was occipital in 29 children, parietal in 16, and temporal and frontobasal in one case each. In seven cases there was parental consanguinity. A familial history of malformations of the central nervous system was encountered in eight instances. Associated systemic abnormalities were present in 23 patients, while central nervous system anomalies were found in 36 children. Cephalocele repair was undertaken on 35 occasions. There were no surgical fatalities in the series. The mean follow-up time was of 7 years. Overall mortality for the whole group was of 17/46 or 36%. Twenty of the 29 survivors had no neurological sequelae, but only 18 children exhibited a competitive intelligence level. A good outcome was found to correlate well with: an average head size at birth, a normal initial neurological condition, operability of the lesions, and an absence of disorders of the neuronal migration. Neurological outcome depended also on the occurrence or not of hydrocephalus, while the intelligence level was mainly related to the absence of cerebral tissue within the sac of the malformation.

Prenatal diagnosis of fetal cephalocele: a sonographic spectrum.

We present the findings in a series of 15 fetuses diagnosed as having a cephalocele. Eleven cephaloceles were located in the occipital region and two each at the vertex and the frontonasal region. Eleven fetuses were diagnosed before 24 week's gestation. Nine families opted for an interruption. Of the two fetuses that went to term, one had a benign meningocele and is growing normally at 18 months, the other died in the neonatal period of associated cardiac anomalies. Of the four fetuses diagnosed after 24 weeks, one is normal (after surgery) at 9 months, two are severely handicapped, and one died in the immediate postpartum period.