Anterior Temporal Approach for Clipping of Upper Basilar Artery Aneurysms: Surgical Techniques and Treatment Outcomes.

BACKGROUND: Upper basilar artery (BA) aneurysms, which consist of basilar tip and BA-superior cerebellar artery aneurysms, are challenging to treat with microsurgical clipping. The anterior temporal approach is one surgical approach used to treat aneurysms in this region. Most previous reports on this approach have consisted of unruptured cases. Assessing mostly ruptured cases in this study, we describe the surgical technique, patient characteristics, and surgical outcomes. METHODS: Twenty-three patients with aneurysms arising from the upper BA who received aneurysm clipping via an anterior temporal approach between December 2015 and January 2019 were retrospectively evaluated. RESULTS: The location of the aneurysms was the basilar tip in 15 patients (65.2%) and the BA-superior cerebellar artery junction in 8 patients (34.8%). Twenty-one patients (91.3%) presented with subarachnoid hemorrhage. Good outcomes (modified Rankin Scale score 0-2) at 3 months were achieved in 55.6% of all patients and in 80% of good-grade patients (World Federation of Neurosurgical Societies grades I-III) and patients with unruptured aneurysms. For patients with subarachnoid hemorrhage, a good outcome was achieved in 75% of good-grade patients. Postoperative transient oculomotor nerve palsy and thalamic infarctions were detected in 7 patients (30.4%) and 2 patients (8.7%), respectively. CONCLUSIONS: With appropriate case selection, the anterior temporal approach was effective and safe for clipping of upper BA aneurysms, especially under subarachnoid hemorrhage conditions.

Healed impact trauma to a Neolithic cattle frontal bone: A posthuman perspective.

Trauma associated with slaughter is identified occasionally archaeologically in the cranial remains of domesticated animals, with evidence for pole-axing occurring in Europe, especially from the Roman period onwards. The injury typically extends through the frontal bone and sinuses to penetrate the braincase, causing haemorrhage, loss of consciousness, brain damage, and death. Evidence for slaughter methods in the British Neolithic, however, is lacking. We report such evidence from a healed blunt-force impact trauma to the frontal bone of a domestic cattle skull from Beckhampton Road Neolithic long barrow, Wiltshire. The injury suggests a failed attempt at slaughter. To our knowledge, this is the first such report for domestic cattle from the British Neolithic. We contextualise this discovery, drawing on research into the role and meaning of faunal remains from Neolithic long barrows in Wiltshire. This work has been undertaken from a posthuman perspective. Thus, we demonstrate the opportunities for paleopathologists to inform and engage within posthumanist interpretative frameworks.

Violence in the Early Bronze Age. Diagnosis of skull lesions using anthropological, taphonomic and scanning electron microscopy techniques.

In this paper we present the study of a skull belonging to a young male from the Italian Bronze Age showing three perimortem injuries on the frontal and parietal bones; the peculiarity of the frontal injury is represented by its singular shape, which may be indicative of the weapon that caused the lesion. The aim of the present study is to examine the traumatic evidence in relation to possible etiological factors, in order to attempt to establish if the lesion occurred peri or post-mortem, and to evaluate if these traumatic injuries could be interpreted as an evidence of interpersonal violence, by combining anthropological, taphonomic and ESEM investigations. The combination of multidisciplinary methods of study can provide important new insights into inter-personal violence.

Post-Surgical Relapse in Metopic Synostosis and Limitations of the Interfrontal Angle as an Outcome Measure.

BACKGROUND: The interfrontal angle (IFA) has been utilized as a surrogate for morphologic assessment of the anterior cranial region in metopic synostosis with success in characterizing presenting severity. Its utility as an outcome measure has not been assessed similarly. In this study, we aimed to determine whether meaningful information relative to shape, and relapse in particular, could be assessed using the IFA. METHODS: Patients with operatively treated isolated metopic synostosis were identified and included based on the availability of "previously obtained" low-dose computerized tomography (CT) scans at (1) preoperative and 2 postoperative (2) postoperative day-3 and (3) 1 year time points. Relapse was calculated as the percentage of the operatively induced change in IFA that was retained after the first postoperative year. RESULTS: After exclusionary criteria, 19 patients were identified. The mean IFA values at the 3 time points were 119.3° (±9.8), 139.6° (±6.3), and 135.3° (±7.1), chronologically. Of the 19 patients, 14 (73.7%) experienced relapse, with this subgroup averaging 62.4% retention of their surgical change after 1 year. Increased preoperative severity and delayed age at surgical intervention were concurrently associated with an increased occurrence of relapse (P = 0.011). Another model utilizes preoperative IFA to predict the change in IFA that would accompany surgery on a case-by-case basis (P < 0.0001). CONCLUSIONS: (1) Fronto-orbital advancement offers immediate correction in the frontal bandeau. (2) Surgical impact, using fronto-orbital advancement, can be predicted using preoperative severity. (3) A component of postoperative relapse occurs within the frontal bandeau and is detectable at 1 year via the IFA. Exclusively, the IFA cannot characterize holistic postoperative relapse due to its inherent anatomical constraints; this supports the cessation of routine postoperative computerized tomography scans for determining outcomes.

Lesión tuberosa parietal secundaria a Sirsasana, una postura de yoga invertida / Tuberous Parietal Lesion Secondary to Sirsasana, the Yoga Headstand Posture

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A re-examination of the human fossil specimen from Backi Petrovac (Serbia).

A fragmented human calotte was discovered during the early 1950s near Backi Petrovac (Serbia), in association with Palaeolithic stone tools. After its initial publication, the fossil specimen remained largely unknown outside of the Serbian academe and no detailed comparative study has ever been carried out. Since the whereabouts of the fossil itself are currently unknown, and given its potential significance for the Pleistocene human evolution, we re-examine the data published by Zivanovic (1966, 1975). Using the original measurements, mostly taken on the frontal bone, and a wide comparative sample of 68 fossil specimens, the fossil was compared and analyzed by statistical multivariate methods. We also conducted a visual examination of the morphology based on the available photographic material. Our analysis reveals phenetic similarity with Middle Pleistocene archaic Homo from Africa and anatomically modern Homo sapiens. However, the absence of primitive cranial traits in Backi Petrovac indicates a clear modern Homo sapiens designation. Although lost at the moment, there is a chance for the re-discovery of the fossil in the years to come. This would give us an opportunity to acquire absolute dates and to study the specimen in a more detailed manner.

Forehead Augmentation with a Methyl Methacrylate Onlay Implant Using an Injection-Molding Technique

BACKGROUND: The forehead, which occupies about one third of the face, is one of the major determinants of a feminine or masculine look. Various methods have been used for the augmentation of the forehead using autologous fat grafts or alloplastic materials. Methylmethacrylate (MMA) is the most appropriate material for augmentation of the forehead, and we have used an injection-molding technique with MMA to achieve satisfactory results. METHODS: Under local anesthesia with intravenous (IV) sedation, an incision was made on the scalp and a meticulous and delicate subperiosteal dissection was then performed. MMA monomers and polymers were mixed, the dough was injected into the space created, and manual molding was performed along with direct inspection. This surgery was indicated for patients who wanted to correct an unattractive appearance by forehead augmentation. Every patient in this study visited our clinics 3 months after surgery to evaluate the results. We judged the postoperative results in terms of re-operation rates caused by the dissatisfaction of the patients and complications. RESULTS: During a 13-year period, 516 patients underwent forehead augmentation with MMA. With the injection-molding technique, the inner surface of the MMA implant is positioned close to the underlying frontal bone, which minimizes the gap between the implant and bone. The borders of the implant should be tapered sufficiently until no longer palpable or visible. Only 28 patients (5.4%) underwent a re-operation due to an undesirable postoperative appearance. CONCLUSIONS: The injection-molding technique using MMA is a simple, safe, and ideal method for the augmentation of the forehead.

Pott's puffy tumor in children.

INTRODUCTION: Pott's puffy tumor is characterized by subperiosteal abscess associated with osteomyelitis of frontal bone. Reports are limited for this rare entity in the antibiotics era but increase during past decade. METHODS: We had clinical analysis of a series with six consecutive pediatric patients of Pott's puffy tumor during 20 years in a tertiary medical center via retrospective chart review. One case was described in detail. RESULTS: Male-to-female ratio was 5:1. The mean age at the time of diagnosis was 13 years-3 months. The risk factors were acute sinusitis in two (33%), chronic sinusitis in two (33%), recent head trauma in two (33%), and acupuncture therapy on skull in one (17%). The commonest presenting symptoms were fever, headache, forehead tenderness, vomiting, and fatigue/malaise (100%). Pott's puffy tumor was diagnosed on average the seventh day after fever, and half had intracranial involvement at diagnosis. All had intracranial infections, and most of them had subdural empyema. The most often involved sinus was frontal sinus (100%). The frontal lobe was the most common site of intracranial infection (100%), two thirds of which are polymicrobial from two or more sites. The initial operation was performed on average on the 5.8th days after diagnosis. Half of the patients underwent reoperation. The mortality rate was 17% (one of six). CONCLUSION: The symptoms of Pott's puffy tumor are inconspicuous even though early intracranial involvement often occurred. The importance of early diagnosis and aggravated and prompt treatment with prolonged antibiotic therapy is emphasized for better outcome.

Predictors of blood loss in fronto-orbital advancement and remodeling.

Fronto-orbital advancement and remodeling for craniosynostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean.

Long-term histologic analysis of bone tissue alteration and healing following Er:YAG laser irradiation compared to electrosurgery.

BACKGROUND: The erbium-doped:yttrium, aluminum, and garnet (Er:YAG) laser is reportedly useful for periodontal therapy. However, the potential thermal damage that Er:YAG laser irradiation can produce on bone tissue has not been fully clarified. The purpose of this study was to histologically examine the effects of the Er:YAG laser on bone tissue and subsequent wound healing compared to electrosurgery in a long-term study. METHODS: Calvarial bone from 30 rats was exposed to contact and non-contact Er:YAG laser irradiation (115 mJ/pulse, 10 Hz) without water coolant, or electrode contact. The treated surfaces were analyzed by scanning electron microscopy (SEM), and the healing process was histologically observed until 12 months post-surgery. RESULTS: Contact irradiation resulted in substantial bone ablation, whereas non-contact irradiation produced slight tissue removal. Histologic and SEM analyses of the lased surface showed no severe thermal damage, except for the production of a superficially affected layer with a microstructured surface. The layer did not inhibit new bone formation, and the ablated defect was repaired uneventfully. Although the thickness of the layer gradually decreased, it generally remained in the cortical bone through the observation period. Electrosurgery produced a large area of thermal necrosis without ablation, and the damaged area was not replaced with new bone. CONCLUSIONS: Unlike electrosurgery, Er:YAG laser irradiation without water coolant easily ablated bone tissue, and thermal alteration in the treated surface was minimal. The superficially affected layer did not interfere with the ensuing bone healing, resulting in favorable repair of the defect.

Pott's puffy tumor after acupuncture therapy.

We report a case of Pott's puffy tumor (PPT) with Pseudomonas infection occurring after acupuncture therapy in a ventilator-dependent child. Acupuncture use has been growing during the past decade in the whole world. Infectious complications range from benign to lethal. PPT is a subperiosteal abscess of the frontal bone associated with underlying osteomyelitis. It presents as a localised swelling of the forehead. This paper describes a 12-year-old girl with PPT. To our knowledge, this is the first case report of PTT caused by acupuncture therapy.

Bone regeneration after topical BMP-2-gene delivery in circumferential peri-implant bone defects.

OBJECTIVES: The aims of this study were to evaluate the rate of bone formation and osseointegration after topical gene delivery with a liposomal vector system carrying bone morphogenetic protein (BMP)-2 cDNA in combination with a collagen carrier and autologous bone as a carrier in freshly created peri-implant bone defects. MATERIALS AND METHODS: Eight domestic pigs received nine calvariae defects each (10 x 7 mm). A dental implant was inserted into the centre of each defect. In the test groups, the remaining space was filled with the liposomal vector/BMP-2 complex combined with a collagen carrier (n=18) or an autologous bone graft (n=18). Control groups were collagen only (n=18) and autologous bone graft only (n=18). RESULTS: There was a significant difference in mineralisation rate in the BMP-2/bone graft (29.9%+/- 4.8 and 68.3%+/- 7.2) and bone graft only (22.6%+/- 2.6 and 49.4%+/- 13.9) groups after 7 and 28 days. Mineralisation values were also significantly higher in the BMP-2/collagen group (21.2%+/- 16.2 and 53.1%+/- 12.5) compared with the collagen-only group (8.2%+/- 7 and 41%+/- 8.1) in two different regions after 28 days. Also the bone-to-implant contact was significantly increased in the BMP-2/bone graft group after 28 days and in the BMP-2/collagen group after 7 and 28 days compared with their control groups. CONCLUSIONS: The results of this study show a significantly positive effect of liposomal vector/BMP-2 on bone regeneration and osseointegration in bony circumferential peri-implant defects.

A fourth hominin skull from Dmanisi, Georgia.

Newly discovered Homo remains, stone artifacts, and animal fossils from Dmanisi, Republic of Georgia, provide a basis for better understanding patterns of hominin evolution and behavior in Eurasia ca. 1.77 million years ago. Here we describe a fourth skull that is nearly complete, lacking all but one of its teeth at the time of death. Both the maxillae and the mandible exhibit extensive bone loss due to resorption. This individual is similar to others from the site but supplies information about variation in brain size and craniofacial anatomy within the Dmanisi paleodeme. Although this assemblage presents numerous primitive characters, the Dmanisi skulls are best accommodated within the species H. erectus. On anatomical grounds, it is argued that the relatively small-brained and lightly built Dmanisi hominins may be ancestral to African and Far Eastern branches of H. erectus showing more derived morphology.

Use of osseointegrated implants in the restoration of head and neck defects.

Osseointegrated implants can be applied to facilitate retention, stability, and support for facial and intraoral prostheses used to restore head and neck defects. At the University of California, Los Angeles, Maxillofacial Prosthetics Clinic, retrospective studies have indicated that in nonirradiated maxillectomy patients, implant survival rates are 82.6 percent. In mandibles reconstructed with fibula free flaps, survival rates are 94.6 percent. Similarly, high implant survival rates have been observed for most sites used to support facial prostheses. Cumulative six-year survival rates for auricular sites exceed 95 percent and for floor of nose sites, success rates exceed 87 percent. However, survival rates are low (53 percent) for implants placed in the frontal bone for retention of orbital prostheses and even lower for irradiated bone sites ranging from 63 percent in the maxilla to 27 percent in the orbit.

Modified frontonasal sinus flap surgery in standing horses: surgical findings and outcomes of 60 cases.

REASONS FOR PERFORMING STUDY: Previous studies of sinus surgery on standing horses have been based on techniques which utilise powered hand bone saws and preserve the bone flap, which was thought to be essential for a good cosmetic result. This report describes a simplified technique applied to the standing horse where the sinus flap construction used a large skull trephine and where the bone flap is necessarily discarded. OBJECTIVES: To assess whether the modified standing frontonasal flap (SFF) surgery offers an effective method to investigate and/or treat sinunasal disorders in the horse. METHODS: The case records of 60 horses subjected to modified SFF surgery were reviewed to analyse the efficacy of the technique when applied to a range of sinunasal disorders in terms of diagnosis, surgical findings, complications and long-term outcomes, including cosmetic effect. RESULTS: Resolution of clinical signs was achieved in 54 out of 60 horses, and for the remainder the SFF technique proved useful on a diagnostic basis. The cosmetic result was, in the opinion of the owners, excellent or satisfactory in 48 of 56 (86%) horses. CONCLUSIONS: The modified SFF technique was found to be practicable and provided satisfactory exposure of the sinus contents for diagnosis and removal of diseased tissue in a range of disorders. An acceptable cosmetic result can be obtained in the majority of horses despite rejection of the disc of overlying bone. Apart from avoiding the risks associated with general anaesthesia, the advantages of the modified SFF sugery are: a reduction of haemorrhage in the standing horse; reduced mucosal engorgement; straightforward anatomical orientation; a comfortable working height; and reduced surgery time. A sound knowledge of the functional anatomy of the area is a prerequisite before embarking on any form of sinunasal surgery. Complications are infrequent and usually transient. POTENTIAL RELEVANCE: The modified SFF technique is a valuable alternative to other invasive methods of sinunasal surgery.

Ivory osteoma of the craniofacial skeleton.

The authors describe the clinical presentation, investigation, and surgical management of two cases of benign ivory osteoma of the craniofacial skeleton. In the first case, a bony mass located over the frontal region had become a cosmetic burden to the patient, and she requested removal with minimal morbidity. Accordingly, an endoscopic procedure, with minimal access incisions located behind the hairline, was devised. In the second case, the patient, a Jehovah's Witness, presented with a long history of slowly enlarging bony masses over the maxilla and in the pterygopalatine space. She finally requested surgical intervention when the symptoms of pain related to fifth nerve compression at the foramen ovale became intolerable. Key aspects of the preoperative and perioperative management strategies used to avoid blood transfusion are detailed, as is the surgical approach, which included a bicoronal scalp flap with temporary removal of the zygomatic arch and the coronoid process. Finally, the etiology, histology, and natural history of ivory osteomas are discussed.

Cranial reconstruction for metastatic breast cancer.

All women with advanced breast cancer who are medically stable despite their disease are candidates for tumor extirpation and reconstruction. Advanced breast cancer today is incurable, and many prognostic factors can be used to try to predict a clinical course and response to therapy; however, no guidelines are available. Our case report most likely represents a metastasis to the calvarium with intracranial extension, reported to occur in about 3 percent of primary breast cancer patients. As demonstrated here, tumor ablation with immediate, one-stage reconstruction of large scalp defects is possible without the need for free tissue transfer or a delay in adjuvant therapy. Local tissue rearrangement has been employed for coverage of defects up to 50 percent of the cranium. The resulting donor defects can be closed with split-thickness skin grafts over pericranium. Serial tissue expansion and rearrangement can be used secondarily to replace skin grafts with hair-bearing scalp. Bony defects can be managed with either autogenous or alloplastic materials. Split-calvarial bone grafts can be harvested from the same operative field and cover small to medium-sized defects. Other sources of autogenous grafts include split ribs and iliac bone. Metals, calcium ceramics, and polymers such as methylmethacrylate can be used to cover intracranial contents and restore calvarial contour when defects are large or when autogenous material is not available. Palliation from tumor burden, prevention of pathologic fracture and oncologic emergencies, controlling pain, and enhancing quality of life are the goals of the oncologic and reconstructive surgeons in cases of advanced breast cancer. These goals are becoming even more important as new forms and combinations of chemotherapy, radiation, and gene therapy are extending the life expectancy of women with breast carcinoma.

Paranasal sinus surgery through a frontonasal flap in sedated, standing horses.

OBJECTIVE: To report experience with paranasal sinus surgery through a frontonasal flap in sedated, standing horses. STUDY DESIGN: Treatment of 10 horses with naturally occurring paranasal sinus disease through a frontonasal bone flap created with the horses standing. ANIMALS: Ten adult horses. METHODS: After restraint and sedation, local anesthetic was injected subcutaneously along the proposed incision line over the conchofrontal sinus and was instilled into the sinuses through a small hole created in the frontal bone. A 3-sided, rectangular, cutaneous incision that extended through the periosteum was created over the frontal and nasal bones. The incision was extended into the conchofrontal sinus using a bone saw, and the base of the flap, on the midline of the face, was fractured. The sinuses were explored, and the horse was treated for the disease encountered. The flap was repositioned; subcutaneous tissue and skin were sutured separately. RESULTS: The horses had few signs of discomfort during creation of the bone flap and during disease treatment. Diseases encountered included inspissated exudate in the ventral conchal sinus (five horses), feed and exudate throughout the sinuses (one horse), occlusion of the nasomaxillary aperature (one horse), polyp (one horse), osteoma (one horse), and progressive ethmoidal hematoma (one horse). CONCLUSION: In selected cases, surgery of the paranasal sinuses can be performed safely on sedated and standing horses through a frontonasal bone flap. CLINICAL RELEVANCE: Performing surgery through a frontonasal bone flap with the horse standing and sedated, rather than anesthetized, eliminates risks and expense of general anesthesia.

Brachycephaly and external pressure.

Browsing through some literatures, I happened to find out some records on the rite of imitation of the child's head to brachycephaly. In 1976, two skulls showing extraordinary forms were excavated out of an ancient tomb at Yean village of Daedong township in Kimhae County in Kyungnam Province, the Republic of Korea. The deformation in Yean village is judged to be an intentional frontal flattening. The frontal bone of deformed individuals is remarkably flattened by a primary deforming force. The parietal bone expands laterally and superoposteriorly as a major compensatory growth. The lambdoid or occipital flattening induced by the counterforce is light and unstable. In the facial skeleton, the maxilla shifts downward as a minor compensatory growth. These findings might be substantially correspondent to the custom in the southern area of Korea in the 4th century A.D. paragraphed by Han chuan of Wei-dynasty record, History of the Three Kingdoms. It described that the people gave a pressure onto the child's forehead with stones in order to mold it for preference. Flatheaded meant "free" among the Chinook and Salish tribes of American Indians. Babies of slaves were denied the year-long beauty treatment--a board tied to the infants' padded skull--that permanently flattened the foreheads of tribal members. Referring to these records, I presume that brachycephaly can be induced by direct extrinsic pressure at least until the soft infant's head gets hard.