[Coma due to syndrome of the trephined]. / Coma secundario a síndrome del trefinado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Coma secundario a síndrome del trefinado / Coma due to syndrome of the trephined

El síndrome del trefinado o craniectomizado abarca manifestaciones neurológicas asociadas a la depresión del flap cutáneo y se distingue del síndrome postraumático por su reversibilidad con el tratamiento reparador del defecto craneano. El coma no es una forma habitual de presentación. Comunicamos un caso de presentación atípica en un hombre de 36 años de edad con antecedente de craniectomía descompresiva, que presentó un cuadro de deterioro neurológico profundo atribuible al síndrome del trefinado, el cual revirtió tras la craneoplastía. En la fisiopatología del síndrome intervienen trastornos cerebrovasculares, metabólicos, hidrodinámicos del líquido cefalorraquídeo e hiperdinamismo de las estructuras encefálicas. El gold standard terapéutico es la craneoplastía. Se requieren estudios de mayor peso estadístico para determinar el tiempo quirúrgico apropiado.

The syndrome of the trephined or craniectomized is commonly referred as neurological manifestations associated to skin flap depression and reversible after craneoplasty, which allows its differentiation from post-traumatic syndrome. We present the case of a male patient, 36 years old, with history of decompressive craniectomy. He evolved with sudden neurological worsening associated to syndrome of the trephined and recovery after craneoplasty. Physiopathology of the syndrome involves cerebrovascular, metabolic and cerebrospinal fluid hydrodynamic disturbances as well as parenchymal hyperdynamic mechanisms. Cranioplasty is the gold standard treatment. Still, studies with statistical power are needed to assess correct surgical timing.

Brain Shift and Pneumocephalus Assessment During Frame-Based Deep Brain Stimulation Implantation With Intraoperative Magnetic Resonance Imaging.

BACKGROUND: Brain shift and pneumocephalus are major concerns regarding deep brain stimulation (DBS). OBJECTIVE: To report the extent of brain shift in deep structures and pneumocephalus in intraoperative magnetic resonance imaging (MRI). METHODS: Twenty patients underwent bilateral DBS implantation in an MRI suite. Volume of pneumocephalus, duration of procedure, and 6 anatomic landmarks (anterior commissure, posterior commissure, right fornix [RF], left fornix [LF], right putaminal point, and left putaminal point) were measured. RESULTS: Pneumocephalus varied from 0 to 32 mL (median = 0.6 mL). Duration of the procedure was on average 195.5 min (118-268 min) and was not correlated with the amount of pneumocephalus. There was a significant posterior displacement of the anterior commissure (mean = -1.1 mm, P < .001), RF (mean = -0.6 mm, P < .001), LF (mean = -0.7 mm, P < .001), right putaminal point (mean = -0.9 mm, P = .001), and left putaminal point (mean = -1.0 mm, P = .001), but not of the posterior commissure (mean = 0.0 mm, P = .85). Both RF (mean = -.7 mm, P < .001) and LF (mean = -0.5 mm, P < .001) were posteriorly displaced after a right-sided burr hole. There was a correlation between anatomic landmarks displacement and pneumocephalus after 2 burr holes (rho = 0.61, P = .007), but not after 1 burr hole (rho = 0.16, P = .60). CONCLUSION: Better understanding of how pneumocephalus displaces subcortical structures can significantly enhance our intraoperative decision making and overall targeting strategy.

Post-operative seizures after burr hole evacuation of chronic subdural hematomas: is prophylactic anti-epileptic medication needed?

INTRODUCTION: There are limited data with regards to the associated risk of post-operative seizures in patients with surgically treated chronic subdural hematomas (CSDHs). The use of anti-epileptic drugs (AEDs) is associated with significant side effects. METHODS: A retrospective chart review was performed on patients operated via burr hole for CSDH in our institution from 2004 to 2013. Post-operative seizures at 1-year follow-up were identified. Demographic data, medical history, and imaging characteristics were recorded. RESULTS: A total of 220 patients were included in the study. Post-operative seizures occurred in 2.3%. The mean time of onset of seizures was 8.4 days. No difference in age and gender between seizing and non-seizing groups was identified p > 0.05. Mean midline shift was 4.6 mm in seizing group vs. 4.2 mm in non-seizing group, p > 0.05. Mean thickness was 14.6 mm in patients without post-operative seizures and 18.4 mm in patients with post-operative seizures, p > 0.05. There was no significant difference in post-operative seizure incidence related to the side or location of the CSDHs. CONCLUSIONS: The incidence of post-operative seizures in patients with CSDH evacuated via burr holes was low. Prophylactic AEDs should not be routinely administered if no other risk factor for seizure exists. Demographic and clinical factors did not appear to influence post-operative seizures.

Síndrome do trefinado: relato de caso / Syndrome of Trephined: A Case Report / Syndrome of Trephined: a case report

Síndrome do trefinado é atualmente uma complicação comum na neurotraumatologia, sendo descrita como uma síndrome na qual ocorre deterioração neurológica acompanhada de sinais e sintomas após a remoção de uma parte considerável de osso do crânio, assim como ocorre na hemicraniectomia. Neste artigo, juntamente com a revisão de literatura, será relatado o caso de um paciente adulto, vítima de acidente automobilístico, com história de traumatismo cranioencefálico (TCE) grave que foi submetido à craniectomia terapêutica, cursando com a síndrome do trefinado.

"Syndrome of the Trephined" or "Sinking Skin Flap Syndrome" is an usual syndrome in which neurological deterioration occurs following removal of a large skull bone flap (for example, in descompressive craniectomy). In this article, we will report the case of a 24 years old male, victim of an automobile accident with severe traumatic brain injury (TBI), which developed the Syndrome of the Trephined.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined'.

UNLABELLED: Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the "syndrome of the trephined" (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. OBJECTIVE: To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. METHOD: We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. RESULTS: Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. CONCLUSION: It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty.

Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined' / Assimetria do diametro da bainha do nervo optico como fator prognostico apos cranioplastia em pacientes portadores da 'sindrome do trefinado'

Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the “syndrome of the trephined” (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. Objective To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. Method We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. Results Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. Conclusion It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty. .

A craniectomia descompressiva (CD) tem papel fundamental no tratamento da hipertensão intracraniana refratária, mas não é isenta de complicações. Uma complicação rara é a “síndrome do trefinado” (ST). Ela ocorre quando as forças gravitacionais se sobrepõem à pressão intracraniana. Objetivo Determinar a utilidade do diâmetro da bainha do nervo óptico (DBNO) como fator prognóstico após cranioplastia. Método Foram acompanhados 5 pacientes trefinados portadores da ST. Estes pacientes foram submetidos à ressonância magnética com medida do diâmetro da bainha do nervo óptico (DBNO). Resultados Dois pacientes apresentaram uma assimetria do DBNO, sendo o diâmetro maior do lado craniectomizado. Para nossa surpresa estes evoluíram melhor do que os que apresentavam o DBNO simétrico. Estes pacientes se tornaram independentes uma semana após, e estatisticamente mais cedo do que os outros. Conclusão Há evidências de que a assimetria do DBNO sirva como fator de bom prognóstico após cranioplastia no pacientes portadores da ST. .

[Neurological paleopathology in the pre-Columbian cultures of the coast and the Andean plateau (I). Artificial cranial deformation]. / Paleopatologia neurologica en las culturas precolombinas de la costa y altiplano andino (I). Deformaciones craneales intencionales.

AIMS: The aim of this work was to study the cranial trepanations and deformations carried out by the ancient Paraca, Huari, Tiahuanaco and Inca cultures. To do so, we conducted a field study involving visits to archaeological remains and anthropological museums on the Andean plateau and the Peruvian coast. DEVELOPMENT: Cranial deformation was more common in the Andean regions and was performed by putting little pieces of wood or compressive bandages on newborn infants' heads in order to modify the growth axis of the cranial cavity. Cranial deformations were performed for aesthetic and magic religious reasons, but were also used as a means of ethnic or social identification, as a symbol of nobility or to distinguish the ruling classes. The immediate consequence of such deformation was the modification of the normal process by which the cranial sutures close. There is a significant correlation between the presence of posterior and lateral wormian bones, according to the degree of artificial deformation. The persistence of metopic suture and exostosis of the outer ear canal have been found in 5% of the skulls belonging to pre Columbine mummies. Other paleopathological findings include cranial fractures (7%), porotic hyperostosis (25% of children's skulls), spina bifida occulta, signs of spinal disk arthrosis and Pott's disease. CONCLUSIONS: Artificial cranial deformation was a very widespread practice in the Andean regions in pre Columbine times.