The "Skull Flap" a new conceived device for decompressive craniectomy/cranioplasty: Feasibility study on cadaver specimen.

BACKGROUND: Decompressive craniectomy (DC) is a procedure that is currently performed with increasing frequency. The reason is that its indications have become much broader. This procedure may be associated with the relevant morbidity in the postoperative stage due to the creation of a large bone defect. On the other hand, cranioplasty is associated too with some of the common complications related to any reconstructive head surgery. The authors present a newly developed device: The "Skull Flap" (SF). This new device allows the surgeon to complete a DC, yet providing at the same time a cranial reconstruction that will not require the patient to undergo a second reconstructive procedure. MATERIALS AND METHODS: Different size and location craniectomies were carried out on four human cadaveric heads; the bone flaps were then repositioned in a more elevated position with respect to the skull edges. The flaps were placed at a distance of 12 and 15 mm from the skull edges using the SF system. Crash tests were conducted on each flap while in open and closed positions to assess its reliability and efficacy. RESULTS: SF was shown to be a strong fixation device that allows satisfactory brain decompression by keeping the original bone flap away from the swollen brain; at the same time, in a later stage, it allows cranial reconstruction in a simple way. CONCLUSION: The SF device was shown to be very easy to use, adaptable, and practical to apply; thus, allowing both satisfactory brain decompression as well as bone flap repositioning at a later time after the brain swelling has subsided.

Jugular foramen paragangliomas: management, outcome and avoidance of complications in a series of 75 cases.

Jugular foramen paragangliomas are rare skull base tumours posing multiple complex diagnostic and management problems. We did a study to evaluate surgical technique, outcome and complications in 75 cases of tumours treated by multidisciplinary approach (i.e. combined neurosurgery, neuroradiology, ear, nose and throat surgery and intensive care unit team). Retrospective study on 75 consecutive patients with jugular foramen paragangliomas treated surgically from 1989 to 2005. Preoperative balloon occlusion test was performed in all patients as well as embolization (100%). A combined limited infratemporal and juxtacondylar approach was used in all patients. Gross total resection was achieved in 59 patients (78.7%). The most common complication was represented by lower cranial nerve deficits in five patients (6.6%), which was only temporary in three. Postoperative facial nerve weakness occurred in five cases (6.6%) and resolved in three of them. The remaining two patients underwent facial nerve reconstruction by hypoglossal/facial nerve anastomosis. Four patients (5.3%) had a postoperative cerebrospinal fluid leak, which was successfully treated by lumbar drainage. Two patients (2.7%) died because of complications related to surgical injury of lower cranial nerves: one patient developed aspiration pneumonia and septicemia and the second one developed a large cervico-bulbar hematoma that led to severe respiratory distress and ultimately global cerebral hypoxia. Paragangliomas are rare and complex skull base lesions that may be managed with low morbidity and mortality if a multidisciplinary approach is considered. Facial and lower cranial nerve postoperative deficits can be limited.

Unilateral asymptomatic testis enlargement in children and adolescents.

In literature a well codified definition of unilateral asymptomatic testis enlargement does not exist. Therefore in these cases the pediatrician or adolescentologist will have to make a clinical and diagnostic evaluation in order to exclude: a) an enlarged testis secondary to tumors, surgery, or endocrinological diseases; b) a small testis due to a previous (ex. cryptorchidism) or current disease (e.g. varicocele).The presence of a mild difference in testis volumes during puberty is not at all rare. This situation may be due to the technique used for evaluation of testis volume or secondary to a varicocele. The identification of variants of testis enlargement is important, because, while on one hand there are conditions without clinical relevance, on the other hand, there are diseases that require early diagnosis and immediate treatment. The Authors report a brief review of the literature and their own clinical experience. 14 patients with unilateral testis enlargement were observed. At the first examination, mean age was 12.3±1.2 years and the volume of the enlarged testis varied between 4 ml and 20 ml (mean volume 10±4 ml) versus 1.5 ml and 10 ml (mean volume 5±2 ml) of the contralateral testis. In 75% of cases the right testis was affected. During the ten year follow-up, the volume of the enlarged testis never exceeded 25 ml and progressive reduction of the difference between the two testes was demonstrated. Therefore, they propose another clinical condition defined as transitory unilateral testis enlargement of puberty.

Skull bone flap fixation - reliability and efficacy of a new grip-like titanium device (Skull Grip) versus traditional sutures: a clinical randomized trial.

BACKGROUND: After completing a craniotomy, it is important to replace the removed bone flap in its natural position in order to guarantee brain protection as well as improve cosmesis. A skull defect can expose the brain to accidental damage, and in cases of larger defects it may also cause the patients psychosocial problems. The ideal fixation device should provide reliable attachment of the flap to the skull and promote fast bony healing to avoid possible pseudo-arthrosis and/or osteolytic changes. MATERIALS AND METHODS: This is a pilot randomized clinical trial on a series of 16 patients undergoing different craniotomies for benign brain lesions in which the bone flaps were replaced using traditional sutures (Prolene 0.0) in 8 cases and with a new skull fixation device (Skull Grip) in the other 8 (randomly allocated). All patients underwent CT scans of the head with 3D reconstruction at day 1 and day 90 postoperatively to evaluate bone flap position and fusion. These scans were independently reviewed by a neuroradiologist. Cosmesis was also evaluated clinically by the surgeon and radiologically by the neuroradiologist in the 2 patient groups. RESULTS: The new "Skull Grip" device has shown stronger fixation qualities with optimal bone flap fusion and increased cosmetic healing features vs. traditional sutures. CONCLUSION: The "Skull Grip" has shown to be a reliable, effective and stronger bone flap fixation device when compared to traditional sutures.

Dorsal epidural spinal lipomatosis.

The authors report a case of a thoracic epidural spinal lipomatosis causing severe neurological deficits along the review of pertinent literature. The patient is a 56-year-old woman who presented with acute onset of severe paraparesis; she was investigated with cervical and thoracic MRI and then surgically managed because of an intraspinal mass compressing the cord. The operation consisted in the excision of the mass confirmed to be a fibrolipoma by pathological analysis. The patient attained complete neurological recovery and at 18 months follow-up she reported a generalised well-being. Thoracic lipomas are rare lesions that presenting mostly with back pain; however, in rare instances they may cause progressive and/or abrupt neurological dysfunction. Appropriate imaging can help in the diagnosis and management of such cases.

Neurosurgery and elderly: analysis through the years.

The aging of the population in westernized countries constitutes an important issue for the health systems struggling with limited resources and increasing costs. Morbidity and mortality rates reported for neurosurgical procedures in the elderly vary widely. The lack of data on risk benefit ratios may result in challenging clinical decisions in this expanding group of patients. The aim of this paper is to analyze the elderly patients cohort undergoing neurosurgical procedures and any trend variations over time. The medical records of elderly patients (defined as an individual of 70 years of age and over) admitted to the Neurosurgical and Neuro-ICU Departments of a major University Hospital in Paris over a 25-year period were retrospectively reviewed. The analysis included: (1) number of admissions, (2) percentage of surgically treated patients, (3) type of procedures performed, (4) length of hospital stay, and (5) mortality. The analysis showed a progressive and significant increase in the proportion of elderly presenting for neurosurgical elective and/or emergency procedures over the last 25 years. The number of procedures on patients over 70 years of age increased significantly whereas the mortality dropped. Though the length of hospital stay was reduced, it remained significantly higher than the average stay. The types of procedures also changed over time with more craniotomies and endovascular procedures being performed. Age should not be considered as a contraindication for complex procedures in neurosurgery. However, downstream structures for postoperative elderly patients must be further developed to reduce the mean hospital stay in neurosurgical departments because this trend is likely to continue to grow.

Uncontrollable high-frequency tachypnea: a rare and nearly fatal complication of endoscopic third ventriculostomy: case report and literature review.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is considered a safe procedure although it carries its rate of risks and complications that may occasionally be life-threatening. CASE REPORT: This is a report about a 48-year-old woman presenting with progressive gait unsteadiness, weakness of the lower extremities and cognitive impairment due to tri-ventricular hydrocephalus. This was treated with standard ETV. In the immediate post-operative period the patient developed a severe and uncontrollable tachypnea requiring sedation, intubation and mechanical ventilation. CONCLUSION: Tachypnea may be an early complication after standard ETV and although its mechanism remains yet unclear, we speculate that it may be related to excessive traction and/or surgical manipulation of the floor of the third ventricle. Supportive care with mechanical ventilation is the mainstay of treatment until spontaneous normalization of the respiratory mechanism occurs.

Endoscopic removal of a central neurocytoma from the posterior third ventricle.

Central neurocytoma is a rare benign tumor that most commonly arises within the ventricular system of young adults. Its occurrence in the posterior third ventricle is one of the least reported presentations. These tumors are usually treated by a combination of either biopsy or open surgical resection, often followed by radiation (Gamma knife or Novalis) with or without chemotherapy. A 37-year-old woman with a posterior third ventricle neurocytoma presented with acute signs of aqueductal stenosis. The patient underwent endoscopic assisted gross total resection of the tumor with the aid of intraoperative laser followed by standard third ventriculostomy; no further treatment was required. The patient did not develop any subsequent neurological deficit. A 36-month follow-up was still consistent with a normal neurological examination. Serial post-operative MRIs show neither residual nor recurrent tumor. Thus, posterior third ventricle central neurocytomas are relatively benign tumors that can be successfully removed using a minimally invasive approach, thereby avoiding both the morbidity related to conventional open craniotomy and the potential toxicity of any adjuvant treatment.

Aggressive scalp carcinoma with intracranial extension: a multidisciplinary experience of 25 patients with long-term follow-up.

Malignant skin cancer of the scalp with skull invasion, dural infiltration and brain involvement is a uncommon lesion. This scenario is most often encountered in patients where initial scalp lesions are not appropriately diagnosed or their extent is underestimated by the patient and/or the doctor. Our study is a retrospective review of 25 patients treated using a multidisciplinary approach (combined plastic surgery/neurosurgery procedure and neuro-oncological management). After a mean follow-up of 7 years, 22 patients did not show local recurrence or distant metastases of their primary disease. Overall, these 22 patients had excellent quality of life; however, three patients died from causes not related to their primary pathology. To obtain a complete and definitive cure, prompt diagnosis of scalp cancers followed by appropriate multidisciplinary management is strongly advised.

Epidemiology and burden of rotavirus-associated hospitalizations in Ferrara, Italy.

Objective of this study was to provide data on hospitalizations for rotavirus gastroenteritis (RVGE) in Ferrara, Italy. The study was conducted analyzing the hospital discharge forms of all children admitted to the Pediatric Department of the University of Ferrara, Arcispedale Sant'Anna, from January 2001 through December 2005. The database was searched for all gastrointestinal diseases and in particular RVGE. During the period under study 3277 children, of which 2038 <60 months of age, were hospitalized; 247 children < 5 years old were admitted for acute gastroenteritis and 89 (4.4% of all and 36% of gastroenteritis-related hospitalizations) had rapid screening tests positive for rotavirus. A seasonal pattern was observed for RVGE with an increase in winter and early spring. The average length of hospital stay was 5.7 days. The median cost of each hospitalized case of RVGE ranged between 1417 and 1595 Euros. The present research confirms that rotavirus gastroenteritis represents an important cause of hospitalization in children and is responsible for significant costs for the Public Health Care System. An effective vaccination program could significantly reduce the incidence of hospitalization and the associated costs.

Carotid cavernous aneurysm presenting as pituitary apoplexy.

The authors report an interesting case with a ruptured internal carotid artery aneurysm that presented as a sellar haematoma mimicking radiologically a pituitary adenoma, and clinically a pituitary apoplexy. A 53-year-old woman presented with a 2-week history of episodic severe headache and vomiting associated, 3 days prior to admission, with left ophthalmoparesis and transient right hemiparesis. Brain MRI showed a large intra- and suprasellar mass suggestive of a pituitary macroadenoma. Hormonal profiles showed hyperprolactinaemia and subsequent cerebral angiography demonstrated a carotid cavernous aneurysm. The patient underwent surgery via a subfrontal approach to manage both lesions. At operation, the suspected pituitary adenoma was revealed to be a sellar haematoma; the aneurysm was successfully clipped. Postoperatively, the patient developed hypotension and right hemiparesis which, as well as the third nerve paresis, progressively improved to full recovery. At 12 months follow-up the patient is neurologically intact and generally well. The clinical features, the management of such a case and the importance of differential diagnosis in the acute stage are emphasised and discussed along with relevant literature.

Anterior cervical corpectomy for cervical spondylotic myelopathy: experience and surgical results in a series of 70 consecutive patients.

Recently the debate over the management of cervical spondylotic myelopathy (CSM) has regained interest; more specifically whether treatment should be operative versus non-operative, raising the question about the real effectiveness of surgery in influencing the natural history of this pathology and about the choice of the most appropriate approach (anterior vs. posterior). The authors report a retrospective review of 70 consecutive patients who underwent elective anterior cervical corpectomy and fusion with iliac crest autograft or titanium mesh and placement of an anterior cervical plate for the treatment of CSM. The patients underwent pre-and postoperative evaluation, including history, and physical and neurological examination. Patients were also evaluated pre-and postoperatively using a modified version of the Japanese Orthopedics Association Scale (mJOA), which provides a fine semi-quantitative graded evaluation of overall function. Upon discharge home, patients were followed for an average of 42 months (range, 12-63 months). Following an anterior cervical decompression of the spinal cord, 94.2% of patients improved their functional status and 5.8% were unchanged; the mean preoperative mJOA score of all patients was 12.2, the postoperative was 15.4 and the amelioration was also documented by neurophysiological studies which showed an increase in amplitude and decrease in latency of somatosensory evoked potentials and motor evoked potential in 47 patients (67%). Older age and longer duration of preoperative symptoms both were not associated with a lower postoperative mJOA score (p < 0.47, p < 0.29, respectively). Single versus multiple level decompression was not predictive of a lower postoperative mJOA score (p < 0.18). Preoperative spinal cord low signal intensity changes on T1-weighted MRI were related to a lower postoperative mJOA score (p < 0.05), whereas spinal cord high-signal intensity changes on T2-weighted MRI were related to a higher postoperative mJOA score (p < 0.01); finally a lower preoperative mJOA score was highly predictive of a lower postoperative mJOA score (p < 0.0005). Anterior cervical corpectomy and fusion for CSM appears to be an effective procedure with a more favorable neurological improvement when compared to posterior decompressive laminectomy, minimally invasive procedures or non-surgical treatment. It is also a safe procedure even in the elderly population, with low morbidity and the potential for permanent spinal cord decompression and excellent bone stability.

The use of virtual fluoroscopy in managing acute type II odontoid fracture with anterior single-screw fixation. A safe, effective, elegant and fast form of treatment.

BACKGROUND: The management of odontoid fractures represents both a clinical and a technical challenge due to the singular anatomy and biomechanics of the region. At present there is still much controversy as far as any form of management (surgical vs. conservative) is concerned and in any case there is not sufficient evidence to support a standardized form of treatment. This study was designed to further evaluate safety and efficacy of anterior odontoid single-screw fixation and to better determine the usefulness of Image Guided Surgery Virtual Fluoroscopy in treating such cases assessing also its advantages over traditional fluoroscopy and CT-guided frameless stereotaxy in the upper cervical spine surgery. METHODS: This was a retrospective review of ten patients presented during a short period of 18 months with acute traumatic Type II odontoid fractures. Nine underwent fixation within a mean of 3 days after injury, whereas a patient had to be operated upon on the 22nd day due to poor alignment with conservative treatment and ongoing instability. All patients postoperatively were fitted in a collar and then followed-up with serial clinical and radiographic examinations. FINDINGS: Radiological signs of fusion were seen in 10 cases (100%) (mean follow-up: 16 months). No complications occurred during the surgical procedure, nor were any instrumentation failures recorded; all patients remained neurologically intact. CONCLUSIONS: We believe that anterior odontoid screw fixation using Image Guided Surgery virtual fluoroscopy is a safe, effective, less time consuming and low x-ray exposure technique and we recommend this as the preferred treatment method for acute Type II odontoid fractures. Moreover, the use of image guided technology affords more precision, confidence and safety enabling the surgeon to approach the upper cervical spine in an easier and faster way.

Dewar benzene as a protecting group? Demonstration of photolithographic crystallization.

The concept of Dewar benzene as a supramolecular protecting group for solid-state aryl-aryl interactions is reported. Photoisomerization of 1,4,5,6-tetramethyl-bicyclo[2.2.0]hexa-2,5-diene-2,3-dicarboxylic acid dimethyl ester (1) to the corresponding benzene isomer proceeds with rapid crystal formation. Herein this property is applied to the photolithographic patterning of crystal domains on a surface. [structure: see text]

Synthesis and crystal structure of a tubular sexithiophene.

[structure: see text] The synthesis of a rigid, tubular sexithiophene is reported. Close intermolecular Cl.Cl interactions play a significant role in defining the crystal structure.

Synthesis of acetylenic cyclophanes via intramolecular self-assembly: evidence of perfluorophenyl-phenyl quadrupole interactions in the solution state.

Reported herein is an example of a solution-state cross-coupling cyclization with an outcome mediated by perfluorophenyl-phenyl electrostatic interactions.

Backbone photochromic polymers containing the dimethyldihydropyrene moiety: toward optoelectronic switches.

The design and synthesis of the first electrically conducting main chain photochromic conjugated polymer incorporating dimethyldihydropyrene is reported, as is the demonstration of the corresponding repeat unit as an optoelectronic redox switch.

Cervical subarachnoid hematoma of unknown origin: case report.

OBJECTIVE AND IMPORTANCE: Spontaneous spinal subarachnoid hematoma is rare, having been reported in the English literature in only seven other cases. We describe the first case of spontaneous subarachnoid hematoma located in the cervical spinal cord of a 43-year-old man. The pathologic examination showed no apparent source of bleeding, but there was evidence of cervical spondylotic myelopathy. CLINICAL PRESENTATION: The patient presented with a 10-day history of severe neck pain, followed by the onset of quadriparesis that was more evident on the left side, urinary retention, and sensory loss below C5. His medical history included hypertension. Magnetic resonance imaging showed a massive hemorrhage in the cervical spinal canal. INTERVENTION: A C4-C5 subarachnoid hematoma was removed. The patient died due to respiratory distress and uncontrollable hypotension on day 6 after surgery. Surgical exploration, neuroradiologic examinations, and autopsy showed no evidence of vascular malformations, tumors, or other possible sources of bleeding. CONCLUSION: After excluding more common causes of spontaneous subarachnoid hematoma in this patient, we suggest that chronic spinal cord compression (spondylotic myelopathy) and arterial hypertension in this patient may have caused the pathogenesis of this rare clinical entity. Experimental data supporting this hypothesis are discussed.

Radiology information and image management system: new approach to PACS with hypermedia capabilities of personal computers.

A system for archiving patient data and images was developed, installed, and evaluated in a radiology department. The system was developed with a relational database program for use with commercially available computers linked with an Ethernet network. The main options of the system are those of a conventional radiology information system: scheduling, registration, examination execution, reporting, archives and statistics, and system administration. However, the main feature of the system is the image archiving capability. Images are associated with patient records after capture by direct acquisition of the video signal or by scanning. Only relevant pathologic images are archived and a commonly employed compression algorithm is used, reducing the total memory requirement for each case to 200-600 kbytes. The diagnosis is still made by reading the original images. The low-resolution images stored in the system have an important role in teaching and consultation and as a first-line archive. Good results have been obtained with this system, which is used by medical and nonmedical staff without any special training.

[The information management of a radiology department: the development of a new type of software for the archiving of alphanumeric data and images]. / Gestione informatica del reparto radiologico: sviluppo di un software di nuova concezione per l'archiviazione dei dati alfanumerici e delle immagini.

The authors report the main characteristics and the goals of the development of the RIS of the II Chair of the Institute of Radiology, La Sapienza University, Rome. The system was developed with a commercial software (4th Dimension), for use with an Ethernet network and Macintosh Apple computers. One of the main problems was to obtain a user-friendly system. The main options of our system are: booking, registration, exam execution, reporting, archives and statistics and system administration. The main characteristics of our RIS is that it allows important images to be archived in limited number and at low resolution. The aim is to use images for consultation and teaching purposes, not for diagnosis which is made on the original images. Low resolution images permit to use limited storage space. Image quality is very similar to that of the original images for the equipment connected on line with the RIS--i.e., US and MR units in our institute. Conventional radiographic and CT images are digitalized by two scanners with maximum resolution of 4k x 4k x 11 bits. To date, good results have been obtained. Our RIS has been used by the medical and non-medical staffs, without any particular instruction and has allowed us to organize and make faster department management and reporting.