Outcomes and recurrence rates in chronic subdural haematoma.

The object of this study was to determine the relationship between outcome (assessed by Glasgow Outcome Scale) and recurrence in chronic subdural haematoma (CSDH). Eighty-two consecutive patients who underwent surgery for CSDH were included in this study. The relationship between the following variables and CSDH recurrence was studied: sex; age; history of trauma; Glasgow Coma Scale (GCS) at the time of admission (stage 1: GCS>12, stage 2: GCS: 8 - 12, stage 3: GCS<8); interval between head injury (when a history of trauma was present) and surgery; presence of a midline shift on CT scans; presence of intracranial air 7 days after surgery; haematoma density; haematoma width; presence of brain atrophy; and Glasgow Outcome Scale (GOS, both quantitative and non-quantitative) at the time of discharge. Throughout the analysis, p<0.05 was considered statistically significant. The results showed lower GCS (p<0.001), higher GOS (p<0.001), presence of intracranial air 7 days after surgery (p=0.002), and a high density haematoma (p<0.001) were significantly associated with recurrence of CSDH. It was concluded that GOS is related with recurrence in CSDH.

Skin-covered midline spinal anomalies: a report of four rare cases with a discussion on their genesis and milestones in surgical management.

BACKGROUND: The differential diagnosis for a dorsal midline mass presenting in a newborn encompasses a wide range of pathological conditions, including spinal dysraphisms, tumoral overgrowths including teratoma and hamartoma, disturbances in regression of fetal tail, and pseudotail formation. OBJECTIVES: To present (a) three rare cases of human tails and one case of tethered cord due to a midline anomaly resembling part of a human limb, (b) to discuss different kinds of clinical and pathological conditions which may be encountered in such newborns, (c) to hypothesize a theory about genesis of these congenital lesions, and (d) to remind drawbacks in preoperative evaluations and surgical management of these newborns. MATERIALS AND METHODS: Four newborns with dorsal midline malformations initially diagnosed as heterotopias are presented. Appropriate preoperative investigations and proper surgical interventions leading to resection of the lesions were performed. All four were skin-covered lesions containing well-differentiated cellular elements of fat, vascular, muscular, bony, and cartilaginous origin. Midline spinal dysraphism was detectable both pre- and intraoperatively only in one case in which cord untethering was also performed along with the first surgical intervention. In the other three "tailed cases," midline bone defect could not be detected in the available X-ray films; consequently, simple excision of the tail-like lesions was done. The first patient had to be explored for repeat untethering of the cord after 4 years, but the others have not yet developed any sign of tethering during an average period of 12 years follow-up. CONCLUSION: Morphological diagnosis of these lesions is not easy, and the attending pediatrician and neurosurgeon should be familiar with the differential diagnosis of such lesions and be prepared for possible time-consuming operation mandatory to achieve total resection of the lesion in a newborn under general anesthesia. Reviewing the possible theories regarding the genesis of such anomalies, it is hypothesized and suggested that all similar cases could have been of hamartomatous origin rather than defects of embryogenesis.

Growing traumatic leptomeningeal cyst of the roof of the orbit presenting with unilateral exophthalmos.

BACKGROUND: Growing skull fractures rarely develop in the skull base region. To the best of our knowledge, only two similar cases have been reported in the English literature. This rare complication, which can occur even after a mild head injury, can produce exophthalmos and threaten the vision. METHODS: The clinical and radiological findings of expanding leptomeningeal cysts extending into the orbit in nine patients referred to the department of Neurosurgery are presented. After appropriate investigations confirming the presence of the expansile retroglobal lesion, surgical exploration was performed via fronto-lateral or the preferred fronto-basal approach. The variable findings are denoted and the relevant literature is also reviewed. RESULTS: Frontobasal head injuries play an important role in pathogenesis of these traumatic expansile leptomeningeal cysts. In this series of nine young girls, 6.65% (six out of nine) injuries happened in the first decade of life with an interval of 2 to 12 months (mean = 6.7, SD = 9.7). High-resolution coronal view computed tomography (CT) scanning with bone density window images, and high intensity cystic lesions visible on T2-weighted coronal MR images were diagnostic clues. CONCLUSIONS: Growing fractures of the anterior skull base may complicate the natural course of healing of any minor frontobasal head injury, especially during childhood. Good quality imaging is mandatory in cases of progressive unilateral exophthalmos. Proper surgical intervention will lead to a good cosmetic result.

Radiation-induced tumors of the central nervous system occurring in childhood and adolescence. Four unusual lesions in three patients and a review of the literature.

The authors report four very rare radiation-associated tumors (or radiation-induced tumors; RITs) of the central nervous system (CNS) and review the literature on this topic. The purpose of this study was to determine the possible relationship between the harmful effects of radiation therapy, the shortest and the longest interval between the time of irradiation and the occurrence of the secondary tumor, and possible predisposing factors. The tumorigenic effects of therapeutic irradiation of the CNS have been mentioned in the literature, but the authors' literature search did not disclose either many reports of cases such as their own or a satisfactory and concise discussion on the different aspects of the late and catastrophic complications of this method of adjunct therapy to the CNS. Four rare cases of RIT in three patients are presented: a unique case of intradural meningioma of the cervical spine, which was irradiated successfully only for the patient to present with a new high-grade cerebral astrocytoma 4 years later, a paraventricular cavernoma and a fronto-temporo-orbital chondrosarcoma. These second RITs became symptomatic in the 17th, 16th and 15th years of life, respectively, in these young patients. The primary lesions were ependymomas, two in the IV ventricle and one in the left hemisphere. The time intervals between radiation and secondary tumor presentation were 14 and 18 years, 9 years and 28 months, in the order in which these patients presented. All the patients survived the second operation except the one with chondrosarcoma, who died in spite of repeated surgical interventions and adjunct therapies. It is concluded that the development of secondary RITs does not necessarily require a very long time interval; that although sarcomas are the most common RITs of the CNS in childhood and adolescence, benign and other rare and curable lesions may also occur in the field or vicinity of the field of radiation; and that in view of the possibility of occurrence of different types of RITs after varying time intervals in a single patient, whole-life followup of similar patients is mandatory.

Meningiomas of the central nervous system occurring below the age of 17: report of 24 cases not associated with neurofibromatosis and review of literature.

The objective of this work was to gain more insight into the controversial characteristics of meningiomas occurring during childhood and adolescence. Management of meningiomas is an important field in pediatric neurosurgery. Every pediatric neurosurgeon has tried to resolve the problems relating to the clinical characteristics, biological behavior and outcome of this interesting and almost benign pathology, which rarely occurs in the first two decades of life. The records on central nervous system (CNS) tumors held by the two major neurosurgery centers of Tehran Medical University and Arad General Hospital were prospectively collected during last 15 years. Complete medical records are available for all 24 cases, and long-term follow-up was achieved 19 patients. All the cases were diagnosed and treated after the introduction of computed tomographic (CT) scanning. Angiography and magnetic resonance imaging (MRI) were performed as complementary studies in some cases. The sample consisted of 13 girls and 11 boys. The age range at the time of diagnosis varied between 2 and 17 years, with a mean of 9.47 and standard deviation of 3.43. Fifteen patients were below 10 years of age (62.5%), and 9 of them were between 10 and 17 years old (37.5%). The most common presenting symptoms, in declining order of frequency, were headache, epilepsy and focal neurological deficits. Similar cases associated with neurofibromatosis either at the time of presentation with meningioma or during the follow-up period were excluded (5 cases). The size of the presenting tumor was more than 5 cm in diameter in 17 cases. The locations of the lesions, taken as the site of the presumed widest dural base in each case were: spinal, orbital, ethmoidal and sphenoethmoidal in 1 case each, petroclival in 2, and tentorial or supratentorial in 18 patients. The only predisposing factor in this series of childhood meningiomas was whole-axis irradiation for previous malignancy in the case presenting with cervical intradural meningioma. There have been no surgical deaths, and gross total excision of the lesions was achieved in 21 cases. Tumor recurrence was observed during the follow-up period in 6 cases (25%). The follow-up period varied between 2 and 165 months, with a median interval of 130.2 months. This series of pediatric CNS meningiomas comprises almost 1.08% of all meningiomas operated on by the authors during the last 15 years and it also accounts for about 1.1% of all pediatric CNS tumors encountered. This series of patients has certain characteristics regarding sex distribution, unusual size, peculiar localizations, special histological features and benign clinical behavior distinguishing it from other series reported in the literature.

Traumatic aneurysms and arteriovenous fistulas of the extracranial vessels in war injuries.

BACKGROUND: Extracranial vessel injuries are potentially devastating complications of penetrating head and neck wounds associated with war conflicts. These vasculopathies may be occlusive or they may lead to formation of traumatic aneurysms (TA) and arteriovenous fistulae (AVF). Even though these penetrating injuries are usually clinically silent and often appear only as small superficial wounds, they may lead to catastrophic hemorrhage or vascular insult. In this study, we attempted to elucidate signs, symptoms and circumstances present in these victims who are at risk of harboring an occult vasculopathy, excluding the occlusive ones and concentrating primarily on TAs and AVFs. MATERIALS AND METHODS: In a prospective study conducted during 8 years of war between Iran and Iraq, we encountered 13 cases of traumatic vasculopathies of the extracranial carotid and vertebral arteries. The type and number of injuries were: carotid-jugular fistula (CJF) 3, carotid trunk or branch aneurysm (CA) 2, superficial temporal artery aneurysm (STA) 3, vertebral artery aneurysm (VA) 2, vertebral arteriovenous fistula (VAVF) 1, ophthalmic artery aneurysm (Oph. An.) 1, and lingual artery aneurysm (Lin. An.) 1. Angiography was performed between the 5th and 30th day after the injury and surgical intervention was performed in all cases. RESULTS: The Glasgow outcome scale (GOS) score was 13-15 in all victims at the time of discharge from the base hospital without any additional neurological deficit. The follow-up period varied from 5 to 8 years in all cases in whom no further morbidity or mortality occurred. Single photon emission computed tomography was the noninvasive tool used for measurement of cerebral blood flow in the cases in which a major vessel ligation was performed; no remarkable change in cerebral blood flow was noted. CONCLUSION: Early recognition of stigmas suggesting possible formation of extracranial traumatic vasculopathies such as TAs or AVFs in the difficult situation of war frontier hospitals should be highlighted for attending physicians or younger neurosurgeons. Performing angiography promptly in suspected cases can pick up such traumatic vascular lesions earlier. Using simpler surgical techniques in situations in which more sophisticated endovascular equipment is unavailable can be life-saving for these usually young victims.

Unilateral exophthalmos caused by traumatic vertebral artery to vertebral and jugular vein fistula: problems in diagnosis and management.

Skull base venous fistulas are rare. A 15-year-old boy was stabbed in the left side of his neck, just below the mastoid process. Two years later, he presented with a protruded and pulsating left eye with red sclera. A soft murmur was audible all over his head and neck. Angiography revealed an arteriovenous fistula between the third portion of the vertebral artery (V3) and the vertebral venous plexus, as well as the ipsilateral jugular vein (VVJF). The fistula recruited several arterial feeders and rising the venous pressure along the outflow system of the skull base had led to unilateral exophthalmos.

Air-gun pellet injuries to the head and neck.

BACKGROUND: Air-gun pellet injuries (AgPI) of the central nervous system (CNS) are rare but catastrophic events. They occur mostly in children and young adults. The entrance is usually either through the orbit or through the neck and the entry wound is so small that it may be disregarded on physical examination in the emergency room. Early recognition and correct management of the possible complications of AgPIs is important and may prevent a poor outcome. METHODS We intend to present our experience with 16 cases of AgPIs of the head and neck referred to the department of neurosurgery during the last 15 years. The characteristic findings on physical examination of the cases and the imaging studies performed are described. Special management undertaken for the rare complications are mentioned and a short literature review is performed on each entity. RESULTS All our cases happened in the first and second decades of life and only in boys playing with toy guns. There were 12 head and face and four neck wounds. Damaged globe that had to be exenterated was the earliest complication, handled by ophthalmologists (four cases). Cerebrospinal fluid (CSF) leakage, meningitis, brain abscess formation, development of traumatic aneurysm (TA), carotid-cavernous sinus fistula (CCF), wandering intracerebral and intraventricular pellet, and splitting of the pellet after striking hard bone were the complications noted. In addition to plain X-ray films, computed tomography (CT) scanning and angiography were diagnostic procedures of choice. CONCLUSIONS The present series of patients is the largest collection of AgPIs to the head and neck reported in the literature in which nearly all the possible complications of such injuries have been reviewed. Early recognition and awareness of the possible cumbersome complications of such a minor penetrating wound can prevent major catastrophies in this young group of victims.

Traumatic aneurysms and arteriovenous fistulas of intracranial vessels associated with penetrating head injuries occurring during war: principles and pitfalls in diagnosis and management. A survey of 31 cases and review of the literature.

In the early days of the war between Iran and Iraq, reports of the sudden deaths of soldiers who previously had survived a penetrating head injury suggested the possibility that a late complication, traumatic aneurysm (TA), could be the cause of this catastrophe. In response, the authors planned a prospective study to perform cerebral angiography in victims with penetrating head traumas, especially in those who had artillery shells or bone fragments passing through areas of dense vasculature. Thirty-one TAs and arteriovenous fistulas were documented. Not all of the lesions, however, were deemed appropriate for surgical intervention. Six aneurysms (19.4%) healed spontaneously and shrank or disappeared on repeated serial angiograms. The authors present their cases and discuss the incidence of TAs, their natural course and behavior, and the special problems encountered in managing these interesting and potentially fatal complications of penetrating head injuries.

Teeth in the cerebellopontine angle: an unusual dermoid tumour.

An hour-glass-shaped multidensity lesion found by CT in a 6-year-old boy who had been admitted to the emergency department after a mild car accident. This lesion turned out to be a congenital dermoid tumour of the right cerebellopontine angle-tentorial notch region containing 12 mature teeth and 14 pseudocarilagenous structures. This is the first case of dermoid tumour containing so many teeth, reported in an asymptomatic person and located off the midline.

Retained broken knife blades within the disc space.

STUDY DESIGN: Four cases in which, during standard laminectomies, knife blades broke deep into the disc space are reported. SUMMARY OF BACKGROUND DATA: These broken knife blades could not be removed at the time of initial operations. RESULTS: Follow-up studies indicated further anterior migration of retained fragments in two cases after ambulation. CONCLUSIONS: Because of the potential hazards of late intraabdominal visceral or vascular injuries, removal of sharp retained fragments at another session is recommended.

Spinal extradural hematopoiesis in adolescents with thalassemia. Report of two cases and a review of the literature.

Extramedullary hematopoietic tissue occurring within the extramedullary space and causing cord compression is an unusual occurrence in childhood and adolescence, and only four cases have been reported during the first two decades of life. We had the opportunity to treat a 16-year-old girl and a 14-year-old boy with paraparesis secondary to extradural extramedullary hematopoiesis. Findings in these cases are discussed, and an attempt is made to stress once more the possibility of congenital hematopoietic rests as the origin of such hyperplastic tissue. The various modes of therapy are discussed and related literature is reviewed.