Total scalp replantation salvaged by changing the recipient vein.

Successful replantation of the avulsed scalp has been reported by a number of authors, and there seems almost no doubt that each single superficial temporal artery and vein is enough to feed and drain the whole scalp if the amputee is not severely torn. As the venous problem is the most common cause of failure, efforts have been made to anastomose reliable veins for drainage. We report a case of total scalp avulsion that was, at first, fed and drained by a superficial temporal artery and an ipsilateral supraorbital vein. Congestion progressed slowly, and exploration revealed patent venous anastomosis without apparent thrombosis. Congestion was relieved when the recipient was changed to superficial temporal vein using a vein graft, leading to complete survival of the scalp. We propose the importance of the capacity of recipient vein, in addition to the anastomotic patency, for successful replantation of the whole scalp. We assume that the capacity of a small caliber recipient vein may be limited even in full dilatation, and the importance of the competent recipient vein should not be overlooked in a large amputee replantation or a large free flap surgery.

Cirsoid aneurysm of the right pre-auricular region: an unusual cause of tinnitus managed by endovascular glue embolisation.

OBJECTIVE: We report an interesting case of a right temporal pre-auricular arteriovenous fistula (cirsoid aneurysm) causing intractable tinnitus successfully managed by transarterial n-butyl cyanoacrylate glue embolisation. CASE REPORT: A 52-year-old female presented with a one-year history of tinnitus and pulsatile swelling in the right pre-auricular region. A colour Doppler ultrasound test and magnetic resonance angiography revealed a high-flow scalp arteriovenous fistula with a feeder vessel from the distal superficial temporal artery, which drained into the corresponding, dilated, tortuous vein. The patient underwent diagnostic digital subtraction angiography. This was followed by transarterial embolisation of the fistula using a 50 per cent mixture of n-butyl cyanoacrylate glue and Lipiodol®, with manual distal venous occlusion. A successful outcome was achieved with instant relief of symptoms. CONCLUSION: Cirsoid aneurysms of the facial region, an uncommon cause of tinnitus, can be effectively managed by endovascular embolisation. This treatment obviates the need for surgery, which is associated with an increased risk of complications such as scarring, deformity and bleeding.

Low-level laser therapy on the viability of skin flap in rats subjected to deleterious effect of nicotine.

OBJECTIVE: The purpose of this study was to evaluate the effect of 830-nm laser in blocking the action of nicotine on the viability of skin flap. BACKGROUND DATA: The authors have analyzed the deleterious effect of cigarette smoke or nicotine on the skin flap alone with evidence of increased skin necrosis in the flap. MATERIALS AND METHODS: Twenty-four Wistar-albino rats were divided into three groups of eight animals each: Group 1 (control), subjected to a surgical technique to obtain a flap for cranial base, laser irradiation simulation, and a subcutaneous injection of saline; Group 2, similar to Group 1, with subcutaneous injection of nicotine (2 mg/kg/day) for a period of 1 week before and 1 week after surgery; and Group 3, similar to Group 2, with skin flaps subjected to a λ 830-nm laser irradiation. The laser parameters used were: power 30 mW, beam area 0.07 cm(2), irradiance 429 mW/cm(2), irradiation time 84 sec, total energy 2.52 J, and energy density 36 J/cm(2). The laser was used immediately after surgery and for 4 consecutive days, in one point at 2.5 cm of the flap cranial base. The areas of necrosis were examined by two macroscopic analyses: paper template and Mini-Mop(®). The pervious blood vessels were also counted. RESULTS: The results were statistically analyzed by ANOVA and post-test contrast orthogonal method (multiple comparisons), showing that the laser decreased the area of necrosis in flaps subjected to nicotine, and consequently, increased the number of blood vessels (p < 0.05). CONCLUSIONS: The laser proved to be an effective way to decrease the area of necrosis in rats subjected to nicotine, making them similar to the control group.

Effect of electrochemical treatment on high-flow vascular malformations in the maxillofacial region.

We explored the effect of electrochemical therapy for the treatment of high-flow venous malformations in the maxillofacial region in 32 patients. We used a method of anaesthesia that was suitable to the site and size of the lesion, and then inserted platinum needles into the lesion in a sterile environment. We protected the normal skin by inserting the cannulas into plastic sheaths, and connected the needles to an electrochemical machine. The common voltage, electric current, and amount of electricity were 6-8 V, 80-100 mA, and 10-20 C/cm(2), respectively. During a follow up period of two months to three years, 18 (56%) patients had a complete response, and 14 a partial response (44%). Electrochemical treatment is a simple, relatively atraumatic method of dealing with high-flow venous malformations that leaves no scars.

[Clinical observation on scalp point injection to improve the cerebral microcirculation for children of early cerebral palsy].

OBJECTIVE: To explore an effective therapy for children of early cerebral palsy. METHODS: One hundred and twenty cases were randomly divided into an acupoint injection group and a medication group, 60 cases in each group. The acupoint injection group was treated with scalp point injection of 0.5-1 mL brain protein hydrolysate into each point, Baihui (GV 20), Fengchi (GB 20) and motor area etc. were selected; the medication group was treated with 10 mL brain protein hydrolysate by intravenous drip. The therapeutic effects in the two groups were observed, and the changes of cerebral blood flow were compared before and after treatment. RESULTS: The total effective rate of 91.4% in the acupoint injection group was superior to that of 73.7% in the medication group (P<0.05), the acupoint injection group could significantly improve the systolic peak velocity (Vs), end diastolic velocity (Ved) and mean velocity (Vm) of middle cerebral artery (MCA) and anterior cerebral artery (ACA), and decrease the vascular resistance index (RI) (all P<0.05), and the improvement degree was superior to the medication group (all P<0.05). CONCLUSION: Scalp point injection therapy can significantly improve the cerebral microcirculation of patients, and has a good therapeutic effect for early cerebral palsy.

Scalp arteriovenous malformation draining into the superior sagittal sinus associated with an intracranial arteriovenous malformation: just a coincidence? Case report.

OBJECTIVE AND IMPORTANCE: Recent experimental and clinical evidence suggests that hemodynamic changes in the venous system can induce the formation of new arteriovenous malformations (AVMs). In a rat model, increased venous pressure induces the formation of soft tissue and dural AVMs. We report a clinical observation that may support these data. CLINICAL PRESENTATION: A 4-year-old boy with a midline scalp AVM draining into the superior sagittal sinus had an associated intracranial/parenchymal AVM. The cerebral AVM increased venous pressure in the superior sagittal sinus as revealed by angiography. INTERVENTION: The scalp AVM was resected, and the intracranial AVM was treated by use of the gamma knife. CONCLUSION: On the basis of reported experimental data and the morphological and hemodynamic characteristics in this patient's two lesions, we suggest that the scalp AVM might have been induced by hypertension in the superior sagittal sinus. This clinical observation supports the notion suggested by experimental studies that hemodynamic changes can induce the formation of associated AVMs.

Is intrapartum vibroacoustic stimulation an effective predictor of fetal acidosis?

OBJECTIVE: The hypothesis of this prospective study is that intrapartum vibroacoustic stimulation (VAS) is an effective predictor of fetal acidosis during labor. Various clinical conditions, such as term versus preterm gestation, first stage versus second stage of labor, and fetal heart rate (FHR) variable decelerations versus late decelerations will be tested. METHODS: During the study period, 113 patients were studied prospectively in either active phase of first stage (n = 53) or during the second stage of labor (n = 60). They were selected from cases exhibiting moderate to severe FHR variable decelerations or late decelerations. The fetuses of study subjects received a VAS for three seconds and FHR changes were recorded. Fetal scalp blood pH or umbilical arterial blood pH was obtained within 15 minutes of VAS. The relationship between FHR responses to VAS and fetal blood pH in term and preterm gestations, the relationship of two tests (VAS and fetal blood pH) to type of FHR decelerations, and the predictability of neonatal morbidity by two tests were analyzed. Where appropriate, Fisher's exact test (p < 0.05 was considered statistically different) and the odd ratio with 95% confidence intervals were used for statistical analyses. RESULTS: Excellent association between acceleration response to VAS and pH > or = 7.20, and between a negative response to VAS (no acceleration or decelerations) and pH < 7.20 were found in the first stage of labor, the second stage of labor, and the combination of both stages together (p = 0.0001, OR = 10.6 [3.3-34.0]). It was observed that negative VAS responses for predicting fetal acidosis (pH < 7.20) were comparable between term (> or = 37 weeks) and preterm (< 37 weeks, > or = 34 weeks) fetuses. Since the preterm fetuses enrolled in the study were limited in number, it is difficult to draw adequate conclusions. The positive predictive value (PPV) of fetal acidosis was 67% in both groups of FHR variable decelerations and late decelerations, but the false negative rate of acceleration VAS response for predicting no acidosis was significantly higher in the group of late decelerations (29% vs 8%, p = 0.034). Finally, both a negative VAS response and fetal acidosis (pH < 7.20) have equal predictability for neonatal morbidity. The PPV of NICU admission by a negative VAS response was two times higher than that of fetal acidosis (PPV = 61% vs 29%, p = 0.038). CONCLUSION: We found that intrapartum VAS was an effective predictor of fetal acidosis in cases of FHR variable decelerations, but its predictability for fetal acidosis in cases of FHR late decelerations was limited. Both VAS and fetal blood pH are good predictors of neonatal morbidity.

Intrapartum fetal stimulation testing.

Intrapartum vibroacoustic stimulation testing (VAST) had a sensitivity of 100%, a specificity of 59.6% and a positive predictive value of 27.6% for the detection of fetal acidosis in this study of 60 cases. The use of VAST could significantly reduce the requirement for fetal capillary blood sampling. However, fetal scalp stimulation (FSS) was found to be an unreliable test to exclude fetal acidosis.

Adjuncts to scalp reduction surgery. Intraoperative tissue expanders and hyaluronidase.

Scalp reduction has become an important part of the cosmetic surgeon's armamentarium in the treatment of male pattern alopecia. Recently, the use of two-stage tissue expansion has been advocated for scalp reduction. Intraoperative tissue expansion obviates many of the disadvantages of delayed expansion and increases the yield of excised scalp by 20-30% over standard reduction techniques in the 20 patients studied. The addition of hyaluronidase to the local anesthetic facilitates its diffusion, enhancing anesthesia and the ease of dissection. Therefore, the use of intraoperative tissue expansion and the addition of hyaluronidase to the local anesthetic are two separate adjuncts to scalp reduction surgery.

Simple and quick non-invasive evaluation of circulatory condition of cerebral arteries by clinical application of the "Bi-Digital O-Ring Test".

Using the "Bi-Digital O-Ring Test," generalized abnormal circulation of the distribution of the 3 cerebral arteries at each side of the brain (i.e., anterior cerebral artery, middle cerebral artery and posterior cerebral artery) can be predicted, without any expensive instruments usually in a few minutes. When abnormality was found in the bifurcation area of the common carotid artery by the "Bi-Digital O-Ring Test," there were always abnormal findings of the area of the brain where circulation was coming from either one or both of the anterior or middle cerebral arteries. When abnormal "Bi-Digital O-Ring" response was found at the vertebral artery and posterior cerebral artery representation point, discovered by the author, at the side of the 6th cervical vertebra (corresponding to the entry point of the vertebral artery into the transverse foramen), the areas of the cerebrum, cerebellum and brain stem where circulation is coming from the posterior cerebral artery, basilar artery and vertebral artery were also abnormal. Most of these abnormalities were found to be associated with problems of the cervical vertebrae and spastic muscles of the neck and shoulders and are often reversible. In this study, the author was able to differentiate abnormal brain circulation of any major branch of arteries in the brain due to organic changes or functional reversible changes by relaxing these spastic muscles and improving the circulation of the neck and shoulder area by giving either manual acupuncture, massage, or transcutaneous electrical stimulation. This in turn often improved brain circulation. If it was a functional abnormality, within a few minutes after one of these procedures the "Bi-Digital O-Ring Test" usually showed normal response or improvement. However, if it was an organic abnormality, the abnormality remained. When the supra-orbital arterial blood pressure at both sides of the forehead decreases below 40 or 30 mmHg, most patients develop so-called "Cephalic Hypotension Syndrome," which is characterized by sleep disturbance pattern; difficulty in concentration; easy forgetfulness of recent events; irritability; decreased pain threshold with or without depression; spastic skeletal muscles, particularly the neck, shoulder and back areas. All of these symptoms can be explained by decreased circulation to the Nucleus Raphe Centralis Superior (controls sleep and waking pattern), Nucleus Raphe Magnus (serotonin & modulation of pain), Nucleus Reticularis Giganto Cellularis (controls muscle tone), etc. in reticular formation.(ABSTRACT TRUNCATED AT 400 WORDS)

Ischemic necrosis of the scalp after preoperative embolization of meningeal tumors.

The authors report two patients who suffered ischemic necrosis of their scalps after preoperative therapeutic embolic occlusion of the external carotid artery and its terminal branches for highly vascular meningeal tumors. Local anesthesia, selective catheterization of the external carotid artery, and radiopaque polyvinyl alcohol and Gelfoam as embolic agents were used. The various complications of external carotid artery embolization are reviewed. The importance of preserving normal branches of the external carotid artery (especially the superficial temporal artery) during embolization and of careful design of the scalp flap to avoid ischemic necrosis is emphasized.