Spontaneous Spinal Epidural Hematoma in an Infant with Developmental Disabilities.

INTRODUCTION: Spontaneous spinal epidural hematomas (SSEHs) are rare in childhood, especially in infants. CASE REPORT: We present the case of a 17-month-old-boy with trisomy 21 and a large SSEH. He was hospitalized for acute onset paraplegia after 6 days of irritability. Nine days after symptom onset, magnetic resonance imaging (MRI) of the spine revealed an extensive epidural hematoma between C7 and T5 causing severe spinal cord compression. After a coagulation disorder was ruled out (12 days after onset), he underwent emergency hemilaminectomy with evacuation of the hematoma. His neurologic impairment gradually improved, and 4 months after surgery he was back to his neurologic baseline. At 18 months after surgery, he was walking independently, although he had some developmental disabilities due to trisomy 21. CONCLUSIONS: Only 20 cases of SSEH in infancy have been previously reported, and this is the first report of SSEH in an infant with developmental disabilities. Because of the non-specific symptoms and difficulty obtaining MRIs in infants, particularly in those with developmental disabilities, the diagnosis and treatment of SSEH may be delayed. However, early diagnosis with MRI and early evacuation of SSEH in patients with severe neurological impairments is important for good outcomes. Attention must be paid to postoperative spinal deformity in infants.

Relaxed pericranial flap for distraction osteogenesis to treat craniosynostosis: a technique for wound reinforcement--technical note.

PURPOSE: Although distraction osteogenesis has been widely accepted to treat craniosynostosis, it occasionally results in wound complications. Positing that they are attributable to the tense pericranium under the scalp, we developed a simple technique to relax the pericranial flap. METHODS: In 12- to 15-month-old infants (mean 13 months), we placed a coronal skin incision and dissected the scalp at the subgaleal layer. Then, we peeled the intact pericranium away from the skull along the planned osteotomy to obtain flaps with pedicles on the caudal part. After osteotomy and setting of the distraction device, the pericranial flaps freed from the scalp flap were repositioned to fit the osteotomy line, dura, and distraction device. The galea and skin were approximated layer by layer. RESULTS: The shape of the skull was successfully corrected, and the bone defect created by expansion was filled by osteogenesis in all patients. During a mean follow-up period of 42.2 months, we encountered no wound complications. CONCLUSIONS: The replaced relaxed pericranium closely adhered to the osteotomy, and the distraction device facilitated vascular growth and bone restoration. Bone resorption was prevented and skin expansion promoted. In patients with iatrogenic dural injury, the pericranium over the injured dura serves as a barrier to prevent cerebrospinal fluid leakage.

Yokukansan improves distress of medical staff, and cognitive function and motivation in patients with destructive and aggressive behaviors after traumatic brain injury.

AIM: Yokukansan (a Japanese Kampo medicine) has been reported to be safe and useful in treating behavioral and psychological symptoms in dementia patients. This study aimed to investigate the effects of yokukansan on destructive and aggressive behaviors in patients after traumatic brain injury. METHODS: From April 2008 to July 2010, 189 patients who suffered traumatic brain injury were admitted to our tertiary emergency center. Of these, patients with destructive and aggressive behaviors were treated with neuroleptics. Seven patients (five men and two women) who could not be controlled by neuroleptics were given yokukansan (2.5 g powder) three times a day before meals. Main underlying conditions included brain contusion in three patients, acute subdural hematoma in two, and acute epidural hematoma in two. The following assessments were carried out at baseline and 1 and 2 weeks after initiation of treatment: the Glasgow Coma Scale for the assessment of disturbed consciousness after traumatic brain injury; Neuropsychiatric Inventory for the distress of medical staff; Mini-Mental State Examination for cognitive function; Barthel Index for activities of daily living; Vitality Index for motivation; presence of adverse effects and drug interactions. RESULTS: After treatment with yokukansan, patients showed significant improvements in Glasgow Coma Scale (P = 0.001), Neuropsychiatric Inventory (P = 0.016), Mini-Mental State Examination (P = 0.029), Barthel Index (P = 0.043), and Vitality Index (P = 0.013). No adverse effects or drug interactions between yokukansan and Western medicines were observed. CONCLUSION: Yokukansan improved the Glasgow Coma Scale, Neuropsychiatric Inventory, Mini-Mental State Examination, Barthel Index, and Vitality Index without any adverse effects or drug interactions with Western medicines in patients with destructive and aggressive behaviors after traumatic brain injury.

Pathophysiological evaluation of cerecyte coil embolization for experimental broad neck aneurysms.

Cerecyte second-generation coils feature inner surfaces coated with an absorbable polyglycolic acid (PGA) polymer. Their use is expected to accelerate aneurysm organization, but time course data are limited. The present experimental study was therefore conducted to clarify the processes by pathological examination. Methods. Two types of experimental aneurysms were initially generated in adult mongrel dogs, one bifurcation and another of lateral wall type. Long-term persistence of each was defined by follow-up angiography for more than 1 year. Embolization of the aneurysms was then performed using only cerecyte coils, and follow-up angiography was conducted after 2 and 4 weeks followed by pathological examination. Results. Organization of both types of broad neck aneurysm was apparent 4 weeks after embolization, which is earlier as compared with already reported data for bare coils.

Altered hemodynamics associated with pathogenesis of the vertebral artery dissecting aneurysms.

The etiology of the vertebral dissecting aneurysms is largely unknown, and they frequently occurs in relatively healthy young men. Objectives and Methods. A series of 57 consecutive cases defined by angiography were evaluated with regard to deviation in the course of the affected and contralateral vertebral arteries. Division was into 3 types: Type I without any deviation, Type II with mild-to-moderate deviation but not over the midline; and Type III with marked deviation over to the contralateral side beyond the midline. Results. The most frequent type of VA running was Type III for the affected and Type I nonaffected side, with this being found in all 17 patients except one. All of the Type III dissections occurred just proximal to a tortuous portion, while in cases with Type-I- and Type-II-affected sides, the majority (33 of 39) occurred near the union of the vertebral artery. In 10 of 57, a non-dominant side was affected, all except one being of Type I or II. With 12 recent patients assessed angiographically in detail for hemodynamics, eleven patients showed contrast material retrograde inflowing into the pseudolumen from the distal portion of the dissection site. Turbulent blood flow was recognized in all of these patients with retrograde inflow. Conclusions. Turbulent blood flow is one etiology of vertebral artery dissection aneurysms, with the sites in the majority of the cases being just proximal to a tortuous portion or union of vessels. In cases with dissection proximal to the tortuous course of the vertebral artery, retrograde inflow will occur more frequently than antegrade, which should be taken into account in designing therapeutic strategies.

A new transvenous approach to the carotid-cavernous sinus via the inferior petrooccipital vein.

OBJECT: The transvenous approach via the inferior petrosal sinus (IPS) is commonly used as the most appropriate for carotid-cavernous fistula (CCF) or cavernous sinus sampling. However, sometimes the IPS is not accessible because of anatomical problems and/or complications, therefore an alternative route is needed. In this paper, the authors present and discuss the utility of a transvenous approach to the cavernous sinus via the inferior petrooccipital vein. METHODS: Four patients, 3 with dural CCFs and the other with Cushing disease, in whom endovascular surgical attempts failed using a conventional venous approach via the IPS, underwent a transvenous approach to the cavernous sinus via the inferior petrooccipital vein (IPOV). One dural CCF case had only cortical venous drainage, the second CCF also mainly drained into the cortical vein with slight inflow into the superior ophthalmic vein and inferior ophthalmic vein, and the third demonstrated drainage into the superior and inferior ophthalmic veins and IPOV. RESULTS: In all cases, the cavernous sinus could be accessed successfully via this route and without complications. CONCLUSIONS: The transvenous approach to the cavernous sinus via the IPOV should be considered as an alternative in cases when use of the IPS is precluded by an anatomical problem and there are no other suitable venous approach routes.

Efficacy of endovascular surgery for ruptured aneurysms with vasospasm of the parent artery.

INTRODUCTION: In the presence of vasospasm it is recommended that surgical clipping for a ruptured aneurysm should be delayed until it disappears, but this may be associated with re-rupture of the aneurysm resulting in a poor outcome. The indications for endovascular coil embolization in such cases are discussed. METHODS: Since November 2002, endovascular coil embolization has been used in 18 consecutive patients with ruptured aneurysm with vasospasm of the parent artery ranging from 2 to 28 days (mean 9 days) after the initial subarachnoid hemorrhage. After successful obliteration of the aneurysm, a microcatheter preceded by a guidewire was introduced into the peripheral vessels with vasospasm of the A2 or M2 portions in order to release the vasospasm mechanically. RESULTS: Endovascular procedures were performed successfully in all but one of the cases (94%), resulting in complete occlusion in 14 of 17 patients and mild dilation of the vasospasm in all 17 patients without technical complications or re-rupture of the aneurysm. In the one case of failure because of a tortuous artery, surgical clipping was performed after disappearance of the vasospasm. Cerebral infarction occurred in four patients, but only one correlated with the distribution of catheterization and the neurological deficits had completely disappeared 3 months after the onset. CONCLUSION: Catheterization of parent vessels in cases of vasospasm is safe for coiling and also mechanically releases vasospasm. Vasospasm of M2 and A2 segments can be treated with microcatheterization only.

Contrast stasis in large and giant internal carotid artery aneurysms as a good prognostic factor for endovascular coil embolization: retrospective study.

OBJECTIVE: Before treatment for large and giant aneurysms, we need some of the predictors to prognose a good result. In this retrospective study, we attempted to determine criteria such as angiographic signs to identify good candidates for effective endovascular surgery. METHODS: This study involved 45 patients with large or giant aneurysms treated by endovascular embolization. For angiographic study, we delivered a bolus injection of contrast medium. All aneurysms were confirmed angiographically and the morphology was defined in detail before endovascular embolization. We divided the patients into two groups based on angiographic findings. Group A (n=16) manifested stasis of the contrast medium in the aneurysm on venous phase. Group B (n=29) exhibited other findings. We retrospectively evaluated the relationship between stasis of the contrast medium in the aneurysm and results of endovascular embolization. RESULTS AND DISCUSSION: There was no significant difference between the two groups with respect to the size of the aneurysm. However, the neck/dome ratio (P=0·04) and size of the neck (P=0·003) were significantly different between groups A and B. The morphological outcome was better in group A than group B (P=0·03). We demonstrate that contrast stasis is a good predictor of outcome in patients with large or giant aneurysms to consider the endovascular embolization. Hemodynamic studies on large patient populations may reveal other factors predictive of a good treatment outcome.

Linear fractures invisible on routine axial computed tomography: a pitfall at radiological screening for minor head injury.

Computed tomography (CT) is now widely used as the only screening method for fractures in patients with head injury. However, clear depiction of a fracture requires a discontinuity in the skull, so linear fractures parallel to the CT slice may not be visualized. We retrospectively evaluated 302 patients with minor head injuries aged from 0 to 91 years, who had undergone routine skull radiography (anteroposterior and lateral views) and head CT to study these types of fracture and discuss the risk of nondetection. Three patients had linear fractures (0.99%) that were invisible on bone window axial CT but detected on skull radiography, which all ran parallel to the scan slice. Two patients developed acute epidural hematoma or traumatic subarachnoid hemorrhage. Evaluation of head injury by only axial CT may miss such fractures and result in sequelae, so diagnosticians should be alert to the possible presence of this type of fracture.

Linear fractures occult on skull radiographs: a pitfall at radiological screening for mild head injury.

BACKGROUND: Skull radiography is widely used to screen for fractures in patients with mild head injury. However, the clear depiction of a fracture requires a gap in the skull separated by the fracture that is wide enough to allow the passage of x-rays. We studied atypical linear fractures that were not visualized clearly, because a specific anatomical configuration hampered the passage of x-rays. METHODS: We retrospectively evaluated 278 patients with mild head injuries who had undergone routine skull radiography (anteroposterior and lateral views) and head computed tomography (CT). We found that some patients negative for linear fracture on skull radiographs were positive on bone window CT scans. RESULTS: Of the 278 patients aged between 2 months and 66 years, 8 (2.9%) manifested a linear fracture on CT scans that presented as a cross section of the fracture oblique to the direction of the x-rays. Four of the 8 developed acute epidural hematoma; 2 of these patients underwent craniotomy. CONCLUSIONS: Radiographic study returned false-negative results, because x-rays were absorbed by the double-layered skull along fractures whose cross section was oblique to the direction of the x-rays. The evaluation of head injury by radiography only may miss these fractures and their undetected presence may result in sequelae such as intracranial hematoma.

Anterior-wall aneurysm of the internal carotid artery successfully treated solely by stenting: With special reference to etiology.

In this case, a ruptured anterior wall aneurysm of the internal carotid artery disappeared on angiography immediately after stent placement. We focus on the underlying nature of the lesion and this possible alternative treatment.

Dural arteriovenous fistulas in the cavernous sinus: clinical research and treatment.

Introduction. The purpose of this paper is to clarify the clinical course, with the dural carotid cavernous fistula (CCF), featuring a pallet of symptoms, paying special attention to radiological findings. Methods. Seventy-six consecutive patients with dural CCFs were investigated in detail, all of whom were defined by angiography. Results. The most common initial symptom was diplopia in 47 patients (62%) and the most frequently observed on arrival were type II, featuring cranial nerve palsies followed by the classical triad in 27, and then type I only with cranial nerve palsies. The time until admission with type I (mean: 6.7 W ± 6.0) was significantly shorter than that with type II (mean: 25.1 W ± 23.5). Branches from bilateral carotid arteries widely inflowing into bilateral carotid cavernous sinus were present in 30 (39%), 20 (26%) of which also demonstrated direct inflow into the intercavernous sinus. type I and II had more multiple venous drainage routes as compared with type III (classical triad only on arrival) and IV (initial development of the classical triad followed by cranial nerve palsy). Conclusion. In our series of dural CCF patients, the most common initial symptom was cranial nerve palsy, mostly featuring multiple venous drainage including cortical drainage. Such palsies should be added to the classical triad as indicative symptoms. Bilateral carotid arteries often inflow into cavernous and intercavernous sinuses, which should be taken into account in choice of therapeutic strategy.

Preventive stitching for migration of a peritoneal catheter into the abdominal wall after ventriculoperitoneal shunting.

Migration of the distal end of a ventriculoperitoneal shunt into the abdominal wall (epi-peritoneal layer) is a complication which is especially likely in obese patients with high intra-abdominal pressure and wide dead space around the catheter remaining after laparotomy. A preventive abdominal stitching method for this complication was developed consisting of sutures beside the catheter penetrating the peritoneum, posterior and anterior sheath of rectus abdominis muscle, and subcutaneous fat. This method was applied to more than 20 patients who underwent ventriculoperitoneal shunting. No patient experienced shunt migration. The technique is easy and safe to perform, avoids leaving a dead space around the peritoneal catheter, and prevents catheter migration.

Meningeal melanocytoma extruded from the skull of a neonate--case report.

Ultrasonography performed at 21 weeks of gestation and magnetic resonance imaging at 23 weeks identified a huge tumor in the occipital region. Premature rupture of the membrane occurred at 28 weeks of gestation, so this baby boy was delivered by emergency cesarean section. Anemia and low blood pressure due to hemorrhage from the surface of the tumor required massive blood transfusion and hemostasis. The tumor was conservatively managed. He manifested symptoms of high output heart failure and persistent infection, necrotizing enterocolitis, and septicemia, and died 51 days after birth. Autopsy examination found the black tumor, weighing 885 g, with a clear boundary with the brain parenchyma. Histological examination showed the tumor was contiguous with the thickened dura mater. The tumor consisted of small, spindle-shaped, round, and polygonal cells without characteristic organized pattern, and positive for S-100 protein and neuron-specific enolase, and negative for HMB-45 and glial fibrillary acidic protein. Ultrastructural study revealed melanin granules within the tumor cells. The diagnosis was meningeal melanocytoma. His skin and spinal cord were unremarkable. Complete tumor resection is considered the best treatment option, followed by incomplete resection with postoperative radiotherapy, but we could not deliver aggressive treatment in our patient because of hemorrhage from the tumor surface and his poor general condition.

Migration of the distal end of a ventriculoperitoneal shunt into the abdominal wall in an obese patient: case report.

A 64-year-old obese woman underwent ventriculoperitoneal shunting for hydrocephalus associated with subarachnoid hemorrhage. On the 10th postoperative day, the distal end of the peritoneal catheter migrated into the abdominal wall and she developed a cyst filled with cerebrospinal fluid around the migrated catheter. The distal end of the catheter was surgically repositioned. We attribute the migration to increased intra-abdominal pressure due to obesity, the use of a low friction hydrogel-processed peritoneal catheter, and the presence of a large dead space around the catheter. The laparotomy must be closed meticulously to prevent this type of migration.

Spinal cord tethering by aberrant nerve root in myelomeningocele: case report.

INTRODUCTION: A 2,796-gram male baby was born at 40 weeks gestation by vaginal delivery. Soon after, he was admitted at our department for treatment of a dorsal appendage. RESULTS AND DISCUSSION: Magnetic resonance (MR) imaging showed a low-position spinal cord, skin-covered myelomeningocele, syringomyelia, and a tethered cord. Resection of the caudal appendage and tethering tissue was performed 22 days after birth under electrophysiological monitoring. Histopathological examination of the caudal appendage that was covered with skin revealed the presence of spinal cord tissue and peripheral nerve tissue. The string-like tethering tissue that extended from the spinal cord to the caudalis was a nerve root, and there was fiberization of the caudalis. The syringomyelia was improved at postoperative MR imaging. To our knowledge, there is no report of a similar case in the literature. We report rare combination of myelomeningocele and spinal cord tethering by aberrant nerve root with thoracic syringomyelia.

Shortening of ventricular shunt catheter associated with cranial growth: effect of the frontal and parieto-occipital access route on long-term shunt patency.

OBJECT: The authors present the difference of shortening the ventricular shunt catheter associated with growth of the cranium between the frontal and parieto-occipital access, a key for long patency of the shunt implanted in children. MATERIALS AND METHOD: Our retrospective study included 28 children. In group A (n=9), the catheter was inserted through a frontal burr hole and in group B (n=19), through a parieto-occipital burr hole. To compare changes that occurred in the interval between the time of insertion and follow-up in the length of the ventricular catheter in the cranium and to assess displacement of the burr used for catheter entry. RESULTS: The results show that ventricular catheter shortening and burr-hole displacement were more pronounced in group A. CONCLUSIONS: This study documents that insertion of the ventricular catheter via the frontal route in children resulted in a higher incidence of shortening due to greater displacement of the burr hole adjacent to the coronal suture. Therefore, we recommend that the parieto-occipital route be used to maintain long-term shunt function.

Acquired lacunar skull deformity following ventriculoperitoneal shunt placement.

A female infant developed hydrocephalus as a result of intraventricular hemorrhage related to premature birth. Radiography showed no sign of lacunar skull deformity (LSD). Lateral and fourth ventricle ventriculoperitoneal shunts were placed. The fourth ventricle shunt required replacement at age 3 years. Radiography and computed tomography showed LSD. Follow-up radiography at age 8 years showed the LSD was becoming unclear. LSD generally appears before birth, and disappears shortly after birth. LSD is most commonly associated with spina bifida cystica or encephalocele. This case of acquired LSD indicates that abnormal disorganized collection of collagen fibers of the skull plates may be triggered by iatrogenic intracranial hypotension even after infancy.

Confirmation of the initial pressure setting in Codman-Hakim programmable valves under magnification--technical note.

Codman-Hakim programmable valves allow neurosurgeons to adjust the opening pressure to the patient's particular clinical needs. However, the pressure control cam is extremely small, so identification of the pressure indicator and its operation is somewhat difficult when initially setting the opening pressure before implantation. We employed a commercial loupe on the program transmitter unit to sufficiently enlarge the view of the cam for clear identification. We recommend that the manufacturer to incorporate a loupe to provide a more sophisticated product.

Lacunar skull deformity and hydrocephalus in infants with myelomeningocele: is lacunar skull deformity a predictor of hydrocephalus development?

OBJECTS: We evaluated whether the presence of lacunar skull deformity (LSD) with myelomeningocele is a predictive factor for subsequent hydrocephalus development. MATERIALS AND METHODS: We reviewed the clinical and radiological records of 18 infants with myelomeningocele, divided the patients into groups with (group A, n=9) and without (group B, n=9) ventriculomegaly at birth and assessed whether the presence of LSD was predictive of the necessity for ventriculoperitoneal shunt (VPS) placement. RESULTS: LSD was present in five group A patients. All nine group A patients underwent VPS placement. Among the group B patients, five had LSD; they underwent VPS placement. A significantly higher proportion of those with ventricle enlargement or LSD at birth required VPS placement (p=0.0001). CONCLUSION: Adding to the ventriculomegaly at birth, the presence of LSD alerts to the necessity to monitor these infants closely to determine the necessity for VPS placement.