MRI of cerebral vein thrombosis in infancy: a case report.

We diagnosed primary idiopathic cerebral vein thrombosis in an infant by MRI. The relative noninvasiveness of the scan, ease of imaging in multiple planes, and good image resolution suggest that the scan may be useful in this disorder.

Tin ear syndrome: rotational acceleration in pediatric head injuries.

An array of signs pathognomonic of child abuse is described for three young children. The eponym "tin ear syndrome" describes distinct unilateral ear bruising, radiographic evidence of ipisilateral cerebral edema with obliteration of the basilar cisterns, and hemorrhagic retinopathy. Rotational acceleration produced by blunt trauma to the ear is shown to be a necessary and sufficient cause for the production of this syndrome. An approximate value of 4,670 radians/s2 produced by a force of 309 to 347 N (70 to 80 lb) results in shear stress and tearing of the subdural veins, loss of cortical vasomotor tone, cerebral hyperemia, herniation, and death. Past history and environmental circumstances implicated child abuse in every case.

Tentorial hemorrhage associated with vacuum extraction.

The clinical and radiologic descriptions of three neonates with tentorial hemorrhage after vacuum extraction are reported. All patients were full term, with Apgar scores of 8 or more; one patient experienced fetal distress during delivery. Within 36 hours after birth, the neonates had multiple generalized seizures; computed tomography or magnetic resonance imaging outlined distinctive tentorial hemorrhages with extension over the superior surface of the cerebellum or inferior surface of the occipital lobe. One patient had diffuse hypoxic-ischemic injury, and another had bilateral temporal lobe infarcts. Treatment included medical control of seizures and intracranial hypertension; one patient had surgical evacuation of bilateral subdural hematomas. Follow-up from 1 to 5 years showed significant developmental delays in two patients. These cases demonstrate that the forces generated on the fetal cranium by vacuum extraction are similar to those produced by forceps and result in tentorial laceration, venous rupture, and subdural hemorrhage. Because these hemorrhages may be associated with significant ischemic injury, serial radiologic evaluation is recommended for the detection of persistent structural abnormalities.

Surgical results and complications in elderly patients with benign lesions of the spinal canal.

OBJECTIVE: To describe the long-term outcome and complications of spinal surgery in a population of elderly patients. DESIGN: Retrospective chart review and clinical follow-up. SETTING: A 700-bed tertiary care midwestern hospital. PATIENTS: Patients 70 years of age or older who underwent elective surgical procedures for the treatment of benign lesions of the spinal canal. MAIN OUTCOME MEASURES: Data obtained from chart review included age, sex, nature and duration of neurological symptoms, activities of daily living (ADL), associated illnesses, length of hospitalization, type of surgery, and complications attributable to surgery. Outcome measurements included changes in neurological symptoms and ADL and a standardized scale obtained from consecutive outpatient visits, telephone interviews, or written responses. RESULTS: Seventy-eight patients with lumbar canal stenosis or soft disc herniations underwent laminectomies, foraminotomies or discectomies. Eleven patients underwent cervical laminectomies for multilevel spondylitic myelopathy. Limb and spine pain were the most common neurological symptoms in patients with lumbar lesions; diminished ADLs were present in eight patients with cervical myelopathies. Six patients died of unrelated causes, and 78 were followed for an average of 27.1 months. Twenty-three (85.2%) of 27 patients with lumbar disc herniations reported improvements or resolution of limb pain while 35 (81.4%) of 43 patients with lumbar canal stenosis reported fair or good results. Five of eight patients with multilevel cervical spondylosis reported improvements of myelopathic symptoms. Twenty-six (28.6%) complications were attributable to 91 surgical procedures including five severe complications and one fatality. Patients with three or more associated illnesses demonstrated a significantly higher incidence of postoperative complications. CONCLUSIONS: Elderly patients with benign lesions of the spinal canal may achieve significant reduction in limb pain and increases in ADL following appropriate surgery, with a tolerable rate of severe complications. The preoperative physical condition of the elderly patient served as an indicator for operative morbidity.

Neurological surgery during the Great War: the influence of Colonel Cushing.

Despite von Bergmann's work in the Franco-Prussian War and Makins' experiences in the Boer conflict, military surgeons in World War I were unprepared for the nature and extent of intracranial injuries. Poor triage, disorganized transportation, incomplete surgery, and sepsis resulted in a mortality of over 50%. In 1915, as a volunteer to the Ambulance Américaine near Paris, Harvey Cushing spent 5 weeks observing the Allied medical system. He quickly recognized the technical importance of early, definitive intracranial surgery and the logistical requirements for a unified triage system located along the main lines of traffic. Cushing returned to France in 1917 as director of Base Hospital #5, known as the Harvard Unit. Immediately detached to the British Expeditionary Force, he operated at a smaller casualty clearing station close to the Belgian front. The patients treated during the third battle of Ypres (Passchendaele) formed the basis of his technical reports. He standardized intracranial injuries into nine categories with separate mortality rates. In addition, he recommended the surgical techniques of en bloc bone resection under local anesthesia with suction debridement and primary two-layer closure. Shell fragments were removed by magnets when possible; dichloramine-T was used as an antiseptic. By reducing infection and secondary complications, Cushing halved the earlier mortality rates. In September 1918, as senior consultant to the American Expeditionary Force, Cushing was in charge of organizing the neurosurgical care for the St. Mihiel and Meuse-Argonne offensives. His instruction of individual surgeons in operative techniques and the creation of identified hospital centers with suitable equipment and trained personnel helped to establish neurological surgery as a military specialty.

Dryander of Marburg and the first textbook of neuroanatomy.

Born in Wetter, Germany, in 1500, Johannes Eichmann (Dryander) studied medicine and anatomy at the University of Paris from 1528 to 1534. In 1535, he was appointed professor of medicine at the University of Marburg. During the next year he held two public dissections, and in 1536 he was the author of the first text illustrating a Galenic dissection of the human brain. An expanded edition of this early book, the Anatomiae pars prior, was published in 1537. These texts represented an important transition from the dogma of medieval scholasticism to the precise observations of Vesalius. The books depicted the brain in eight figures, with four additional plates describing the skull, skull base, and cranial sutures. Detailed illustrations of the dura mater, cerebral cortex, and posterior fossa structures with clear, but inaccurate, relationship to the cranial nerves demonstrated Dryander's reliance on his own dissections. In 1542, he published a translated edition of Mundinus' anatomy. As was common at that time, the text plagiarized a portion of Vesalius' Tabulae sex, which resulted in the famous anatomist's anger. Despite this, Dryander continued to write on medical subjects as well as mathematics and astrology until his death in 1560. Because he was a progenitor of rational scientific thought, his earlier books represented an important advance in the progression to modern anatomic description and illustration.

Neurological surgery in the nineteenth century: the principles and techniques of Ernst von Bergmann.

Born in Latvia in 1836, Ernst von Bergmann received his medical education and first academic position at the University of Dorpat in Russia. In 1866, he served as a military surgeon in the Prusso-Austrian War, followed by duty in the Franco-Prussian War of 1870. He was appointed to the faculty of the University of Würzburg in 1878 and 4 years later moved to the University Clinic in Berlin. As a professor and chairman of surgery, he taught until his death in 1907. Von Bergmann practiced general surgery but devoted a large part of his career to the treatment of neurological diseases. Known for his development of aseptic technique, his early military experiences directed his attention to cranial trauma and, ultimately, neurosurgery. In 1880, he authored his first textbook, which described missile ballistics and animal experiments first demonstrating the physiological response later known as "the Cushing reflex" and advocated meticulous intracranial debridement with thorough closure after trauma. Twenty years later, as senior editor of the massive System of Practical Surgery, his contributions included pediatric neurosurgery, successful treatment of abscesses and tumors, diagnostic radiography, and cerebral localization using external landmarks and the neurological examination. Revered by his students and honored by his colleagues, von Bergmann became a proponent for aggressive neurosurgical treatment. His skilled techniques, developed in parallel with accurate experimental physiology, advanced 19th century surgical progression and formed a solid framework for the advances of neurosurgical specialists.

A risk/benefit analysis of spinal manipulation therapy for relief of lumbar or cervical pain.

Approximately 12 million Americans undergo spinal manipulation therapy (SMT) every year. Renewed interest in this method requires an analysis of its reported risks and possible benefits. This review describes two patients with spinal cord injuries associated with SMT and establishes the risk/benefit ratios for patients with lumbar or cervical pain. The first case is a man who underwent SMT for recurrent sciatica 4 years after chemonucleolysis. During therapy, he developed bilateral sciatica with urinary hesitancy. After self-referral, myelography demonstrated a total block; he underwent urgent discectomy with an excellent result 3 months after surgery. The second patient with an indwelling Broviac catheter and a history of lumbar osteomyelitis underwent SMT for neck pain. Therapy continued for 3 weeks despite the development of severe quadriparesis. After self-referral, he underwent an urgent anterior cervical decompression and removal of necrotic bone and an epidural abscess with partial neurological recovery. An analysis of these cases and 138 cases reported in the literature demonstrates six risk factors associated with complications of SMT. These include misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine. Clinical trials of SMT have been summarized in several recent articles.(ABSTRACT TRUNCATED AT 250 WORDS)

Children with cerebral venous thrombosis diagnosed with magnetic resonance imaging and magnetic resonance angiography.

From 1985 to 1991, 13 children were diagnosed at the University of Illinois College of Medicine at Peoria, Saint Francis Medical Center, with cerebral venous thrombosis (CVT) by magnetic resonance imaging scan. Ages ranged from newborn to 5 years. Six children were premature neonates, five were term neonates and two were 5 years old. In the premature neonates, thrombosis was usually associated with other problems. All the term neonates had seizures. In all neonates, thrombosis resolved without any specific treatment. In the two older children, one presented with pseudotumor cerebri and one with coma. These children required neurosurgical intervention. Follow-up magnetic resonance imaging scans were obtained in 9 of 13 children and showed thrombus resolution in each case. Three children were studied in the acute and convalescent stages by magnetic resonance angiography using time-of-flight techniques. Each follow-up magnetic resonance angiogram showed improvement in venous flow consistent with their clinical course and other imaging studies. We conclude that 1) CVT in children encompasses a range of clinical conditions which may or may not require neurosurgical intervention; 2) magnetic resonance imaging is superior to other modalities for the diagnosis of CVT; and 3) magnetic resonance angiography is an alternative means to monitor the evolution of CVT and efficacy of therapeutic intervention.

Surgical results in obese patients with sciatica.

A prospective study was done to determine the effect of obesity on the surgical results in patients with intractable sciatica. One hundred ten patients entered the study over an 8-month period. Five patients (1 obese) were excluded. Seventeen patients were included in the obese group. The two populations did not differ in age, sex, occupation, level of disc herniation, involvement of compensation, length of hospitalization, duration of disability, or incidence of surgical complications. At the 6-month follow-up assessment, 14 obese patients vs. 80 nonobese patients rated their surgical results good or excellent. Patients with postoperative weight loss were equally distributed between the groups. The data demonstrate that obesity should not be considered a prognostic factor when patients are eligible for surgical therapy.

Incidence and neurodevelopmental outcome of periventricular hemorrhage and hydrocephalus in a regional population of very low birth weight infants.

During the years 1984 to 1987, 459 very low birth weight (VLBW) infants were admitted to a state-designated Level III Neonatal Intensive Care Unit. Cerebral sonography performed in a standardized sequence and graded with the Papile scale diagnosed 97 (21.1%) children with periventricular hemorrhage (PVH). The incidence of PVH declined from a peak of 26.6% in 1985 to 16.4% in 1987, associated with an increase in the incidence of inborn admissions (including maternal transport) from 62.0% in 1984 to 80.4% in 1987. During initial hospitalization, the occurrence of both low-grade (Grades I and II) and high-grade PVH was associated with a significantly higher incidence of perinatal risk factors compared with a concurrent population of VLBW infants without PVH. Developmental follow-up was achieved in 93.3% of VLBW infants without PVH and 95.7% of VLBW infants with PVH who survived their initial hospitalization. The incidence of abnormal outcome ranged from 7 of 37 infants with Grade I PVH to 7 of 8 VLBW infants with Grade IV PVH. Only 1 of 16 VLBW infants with high-grade PVH demonstrated normal motor and cognitive development. Active hydrocephalus developed in 12 infants; 11 sustained a high-grade PVH. Appropriate treatment of intracranial hypertension did not modify the neurodevelopmental outcome. In conclusion, this regional population of VLBW infants demonstrated a decline in the incidence of PVH during the years 1984 to 1987 associated with an increase in the incidence of inborn admissions. The risk of abnormal neurodevelopmental outcome was elevated for all grades of PVH. A 12.0% incidence of hydrocephalus was associated with high-grade PVH, and appropriate treatment did not alter the poor prognosis.

Angiographic demonstration of a spinal epidural arteriovenous malformation. Case report.

A 16-year-old boy presented with acute midline thoracic pain followed by rapidly progressive paraplegia. The initial neurological examination demonstrated a complete sensory and motor paraplegia, which significantly improved spontaneously over the following 2 days. Magnetic resonance imaging revealed a posterior epidural hematoma extending from the T-4 to T-6 vertebrae, and spinal angiography demonstrated an arteriovenous malformation (AVM) with a nidus of abnormal epidural vessels at the level of the T-5 vertebra, which was confirmed surgically. This case represents one of the first reports of a spinal epidural AVM confirmed by angiography.

Dissociation of cerebral blood flow, glucose metabolism, and electrical activity in pediatric brain death. Case report.

A 2-month-old infant demonstrated clinical brain death 48 hours after suffering a closed head injury accompanied by cardiac arrest. Two nuclear cerebral blood flow (CBF) studies demonstrated normal perfusion. On the 11th day following injury, cerebral electrical activity ceased and a normal glucose metabolic gradient between gray and white matter was documented on positron emission tomography. Autopsy revealed widespread necrosis with mononuclear cell infiltrates throughout all cerebral cortical layers. Nine children have previously been described with clinical brain death, electrocerebral silence, and evidence of CBF by radionuclide scan. The dissociation between cerebral electrical activity and blood flow may be explained by an increase in cranial volume allowed by the expansile neonatal skull, preventing both intracranial hypertension and a reduction in perfusion pressure. The persistence of glucose metabolism may be associated with the presence of inflammatory microglial cells in the ischemic cortex. The authors conclude that persistence of CBF and glucose metabolism in brain-dead children may not indicate neuronal survival. If repeated neurological examinations with or without electroencephalography support the diagnosis of brain death, the presence of CBF and glucose metabolism should not alter this conclusion.

Spontaneous regression of giant arteriovenous fistulae during the perinatal period. Case report.

A unique case of spontaneous regression of giant arteriovenous fistulae during infancy is described in this report. A female infant, the product of normal labor and delivery, demonstrated severe ventriculomegaly and an intracranial hemorrhage at birth. Cerebral angiography at 5 days of age revealed several large fistulae fed by the anterior and middle cerebral arteries draining into the deep venous system through a dilated internal cerebral vein and ectatic vein of Galen. Two days following the angiogram, a second intracranial hemorrhage occurred. Active hydrocephalus developed over the next 6 months and was treated with ventriculoperitoneal shunting. When the child was 8 months of age, angiography failed to demonstrate the fistulae. It was postulated that pressure effects from the intracranial hematoma and long-standing intracranial hypertension as well as stenosis in the anomalous venous outflow resulted in vascular stasis, venous thrombosis, and selective arterial occlusion. Hydrocephalus was a result of the compression of the intraventricular foramina by dilated embryonic vessels. This anomaly, predominantly involving the anterior circulation, may be homologous to the vein of Galen aneurysm in the posterior circulation.

Odontoid fractures in elderly patients.

This retrospective analysis describes the clinical characteristics, treatment, and outcome of 19 patients aged 80 years or older with odontoid fractures. The fractures were due to falls in 15 patients (78.9%) and were associated with motor-vehicle accidents in four. Type III fractures were seen in three patients and type II fractures in 16. No patient suffered a neurological injury associated with the fracture. Five patients (26.3%) died during hospitalization; factors contributing to their death included prolonged bed rest, associated injuries, and concomitant medical illnesses. The mean follow-up period in the remaining 14 patients was 28.8 months (range 5 to 72 months). Eight patients with a posterior displacement of 5 mm or less were treated with cervical immobilization, three of whom showed a stable non-union of the fracture site at follow-up review. One patient with 10-mm displacement refused operative treatment. Three of the patients without surgical treatment subsequently died from unrelated causes; all remaining patients resumed their routine activity. Five patients with displacement of 5 mm or greater and instability at the fracture site were treated with posterior cervical fusion of C1-2 using wire and autologous iliac bone grafts. In this group, no operative morbidity or mortality occurred and stable constructs developed in all patients; one patient died from an unrelated cause during the follow-up period and the other patients resumed their normal activity. Prolonged bed rest caused respiratory complications in two of six patients who survived initial hospitalization; two of three patients treated with rigid immobilization developed complications that required alternative treatments.

Medical imaging of fetal ventriculomegaly.

Five cases of fetal ventriculomegaly are described in detail. Following ultrasonography, either computerized tomography or magnetic resonance imaging was used in an attempt to clarify the structural pathology of the ventriculomegaly. In two patients, a precise diagnosis was achieved while a probable diagnosis was established in a third patient. The diverse etiology of fetal ventriculomegaly in these five cases demonstrates that ancillary medical imaging may be necessary to achieve diagnostic precision prior to therapeutic intervention.

Diagnosis of subdural hemorrhage in utero. Case report.

A case is presented of subdural hemorrhage diagnosed in utero at 31 weeks of gestation by fetal ultrasonography. Following delivery, clinical examination of the infant revealed hydrops fetalis, right-sided cardiomegaly, hepatic dysfunction, and coagulopathy. Prompt resolution of these problems led to a retrospective diagnosis of premature closure of the foramen ovale as the precipitating event. The causes of previously reported cases of intrauterine cerebral hemorrhage are reviewed and compared to the present case.

MRI and evoked potentials in a child with hydranencephaly.

Magnetic resonance imaging and evoked potential studies were performed on an infant with hydranencephaly. Magnetic resonance imaging demonstrated the absence of cortical tissue with a structurally intact mid- and hind-brain. Evoked potentials confirmed the loss of cortical activity with preservation of brainstem function. These diagnostic tests gave efficient and precise information concerning the extent of the intracranial pathology and prognosis.

Magnetic resonance imaging of spinal injury.

Magnetic resonance imaging (MRI) was performed on 30 patients following spinal injury (SI). Spin-echo sequences and surface coils were used for all patients. Plain radiographs, high-resolution computed tomography (CT), and MRI were compared for the delineation of bone, disc, and ligament injury, measurement of sagittal spinal canal diameter and subluxation, epidural hematoma, and spinal cord structure. Myelography or intrathecal contrast-enhanced CT were not performed on any of these patients. Magnetic resonance imaging accurately delineated intraspinal pathology in two of four patients with acute penetrating SI, and was normal in the other two patients. In 16 patients with acute nonpenetrating SI, MRI was superior to CT for visualizing injuries to discs, ligaments, and the spinal cord, while CT was superior to MRI in characterizing bony injury. Computed tomography and MRI provided similar measurements of subluxation in six of six patients and of sagittal spinal canal diameter in three of four patients. In ten patients with chronic SI, MRI demonstrated post-traumatic cysts, myelomalacia, spinal cord edema, and the presence or absence of spinal cord compression. In patients with acute penetrating SI and chronic SI, MRI provided comprehensive clinical information. In patients with acute nonpenetrating SI, the information obtained by MRI complemented the data given by plain radiographs and CT, allowing clinical decisions to be made without the need of invasive imaging modalities.

Neurologic birth trauma. Intracranial, spinal cord, and brachial plexus injury.

The variety of perinatal neurologic injuries described in this article suggests that any region of the central or peripheral nervous system may be affected by the birth process. Fortunately, these injuries are infrequent and, in many instances, resolve without any intervention.