Calvarial hemangiomas: Series of 6 cases and review of literature.

Calvarial haemangiomas are benign, vascular tumours of the skull involving parietal and frontal bones. Mostly these lesions remain asymptomatic, and present with cosmetic deformity, headache, uncommon neurological symptoms and reported as case reports and case series. The radiological appearance can range from sessile growing intradiploically to globular and the lesions may extend outwards or inwards after eroding the outer and inner tables of the skull. "Sunburst appearance" and "Wagon-wheel sign" are classical radiological findings but the lesions may present simply as a lytic expansile or even sclerotic calvarial mass. Because of varied clinical presentation and atypical radiological characteristics, the final diagnosis can be clinched by histology only. In selected cases where these lesions are not cosmetically acceptable, en bloc resection with tumour free margins followed by cranioplasty is the treatment of choice. Most reports of calvarial haemangiomas in literature are in the form of case reports.

Modifying skin flaps for achieving very large decompressive craniectomies in malignant middle cerebral artery territory infarcts: A technical note.

INTRODUCTION: Decompressive craniectomy is a well described treatment to salvage life in large middle cerebral artery (MCA) territory infarcts. The size of the craniectomy is limited by the size of the skin incision and very large craniectomies need large skin flaps that are prone to necrosis at the wound margins. MATERIAL AND METHODS: We describe two modifications in the skin flap that we have used in 7 patients to achieve very large bony decompressions in malignant MCA infarctions without compromising on flap vascularity. One consists of a linear extension posteriorly from the question mark or reverse question mark incision while the other is an "n" shaped incision. RESULTS: With these modifications we achieved craniectomies of size 15.6-17.8 cm in the anteroposterior and 10.7-12 cm in vertical axis of the bone flap removed in our patients. There were no additional procedural or wound related complications in a 6-month follow up. CONCLUSIONS: Removal of a standard size bone flap may achieve suboptimal decompression in cases of large MCA territory infarctions. Imaginative tailoring of skin flaps helps to remove larger volumes of skull with no added procedural morbidity.

Spinal Subdural Hematoma following Epidural Anesthesia.

The spinal subdural space is an avascular, potential space and is a rare location for intraspinal hematomas. Compared to spinal epidural hematomas, spinal subdural hematomas are uncommonly described complications of lumbar puncture for spinal or epidural anesthesia, particularly in patients who have no pre-existing bleeding disorders or history of antiplatelet or anticoagulant intake. We describe a 19-year-old girl who had a large thoracolumbar spinal subdural hematoma following epidural anesthesia for elective cholecystectomy with no pre-existing bleeding diathesis that caused rapidly developing paraplegia that evolved over the next 2 days following surgery. Nine days after the initial surgery she underwent multilevel laminectomy and surgical evacuation with eventual satisfactory recovery. Even epidural anesthesia without thecal sac violation can result in bleeding in the spinal subdural space. The possible sources of bleed in this space may be from injury to an interdural vein or extravasation of subarachnoid bleed into the subdural space. When neurological deficits occur, prompt imaging is mandatory and early evacuation yields gratifying results.

Epidural Fluid Collections After Cranioplasty.

Background: Common complications following cranioplasty (CP) include infections, seizures, bone flap resorption, and intra-cranial hemorrhages. Epidural fluid collections (EFCs), often seen in the immediate post-operative scan as hypo-dense accumulations below the bone flap, have been very infrequently discussed in the literature as in the majority of the cases, they are small, get resorbed spontaneously, and usually do not cause neurological deficits. Objective: To document our experience with EFCs that needed re-operation and analyze their clinical and radiological findings. Materials and Methods: We describe a series of six cases of symptomatic EFCs following CP that necessitated re-operation in a series of 89 cases over 7 years. Conclusions: EFCs following CP have a different pathogenetic mechanism compared to post-operative epidural hemorrhages. Meticulous surgical techniques can reduce their incidence. Symptomatic EFCs can be evacuated by either re-opening the flap or placing burr holes in the replaced bone. EFCs may become symptomatic even a few days after CP.

Everted Pedicled Temporalis Fascial Flap to Augment Pedicled Pericranial Flap for Lax Duraplasty in Decompressive Craniotomy: A Cost-Effective Procedure.

Decompressive craniotomy is a commonly performed surgery to relieve raised intracranial pressure. At the end of the procedure, it is the convention to cover the exposed brain by performing a lax duraplasty which allows for both brain expansion and provides protection to the underlying parenchyma. Various commercially available dural substitutes are used for this purpose. These have the drawback of being both expensive and nonvascularized. We propose a technique of using pericranium along with everted temporalis fascia (both being locally harvested vascularized pedicle flaps) that can suffice in a vast majority of cases for covering the brain.