Dementia in custody: A historical and forensic approach.

The constant ageing of the population extends to the population behind bars. We consider and summarise medical, ethical, legal and societal concerns raised when older adults with dementia are charged and put into custody.Dementia in custody is a relatively new concept in forensic science. When you take into account the adversarial nature of the judicial system and the hardship posed by correctional facilities, an older adult with severe cognitive problems will increases the complexity of the situation.The possibility of an octogenarian in cognitive decline being detained in police custody is less remote than it seemed half a century ago.

Emergency decompressive craniectomy after removal of convexity meningiomas.

BACKGROUND: Convexity meningiomas are benign brain tumors that are amenable to complete surgical resection and are associated with a low complication rate. The aim of this study was to identify factors that result in acute postoperative neurological worsening after the removal of convexity meningiomas. METHODS: Clinical evaluation and neuroradiological analysis of patients who underwent removal of a supratentorial convexity meningioma were reviewed. Patients were selected when their postoperative course was complicated by acute neurological deterioration requiring decompressive craniectomy. RESULTS: Six patients (mean age: 43.3 years) underwent surgical removal of a supratentorial convexity meningioma. Brain shift (mean: 9.9 mm) was evident on preoperative imaging due to lesions of varying size and perilesional edema. At various times postoperatively, patient consciousness worsened (up to decerebrate posture) with contralateral paresis and pupillary anisocoria. Computed tomography revealed no postoperative hematoma, however, did indicate increased brain edema and ventricular shift (mean: 12 mm). Emergency decompressive craniectomy and brief ventilator assistance were performed in all patients. Ischemia of the ipsilateral posterior cerebral artery occurred in 3 patients and hydrocephalus occurred in 2 patients. Outcome was good in 2, fair in 2, 1 patient had severe disability, and 1 patient died after 8 months. CONCLUSIONS: Brain shift on preoperative imaging is a substantial risk factor for postoperative neurological worsening in young adult patients after the removal of convexity meningiomas. Emergency decompressive craniectomy must be considered because it is effective in most cases. Other than consciousness impairment, there is no reliable clinical landmark to guide the decision to perform decompressive craniectomy; however, brain ischemia may have already occurred.

Superficial temporal artery pseudoaneurysm presenting as a growing, pulsatile, and tender mass.

BACKGROUND: Superficial temporal artery (STA) pseudoaneurysms have been reported in the literature since the mid of seventeenth century from Bartholin, however, there is an increasing number of cases, suggesting a diversity of etiological factors. Among these, traumatic events, even of an iatrogenic nature, have been identified as causative factors for nonspontaneous STA pseudoaneurysms. Regional pain and tenderness, troublesome pulsations of the mass, cosmetic concerns as well as the risk of bleeding warrant a thorough evaluation and a definite interventional approach to the condition. CASE DESCRIPTION: A 21-year-old Caucasian male searched medical advice for a growing, tender, and pulsatile mass on his right temple, with isolated and short episodes of lancinating sensations, after sustaining a blunt trauma following a hit with a stick half a year before the admission. Enhanced cranial computed tomography and angiography confirmed the diagnosis of an STA pseudoaneurysm. A direct percutaneous aspiration, as well as ultrasonography, was performed prior to the neurosurgical intervention, with the complete removal of the mass. CONCLUSIONS: STA pseudoaneurysms require a careful evaluation and a conclusive approach in order to avoid the risk of a growing mass and other nonremote complications such as bone erosions and bleeding. Different treatment options are available, including endovascular obliteration and embolization, however, surgical removal after ligation of the afferent and efferent segments of the vessel seem to be highly effective.

Sleep-disordered breathing and stroke: A relation to be considered.

Stroke is a leading cause of death and disability. Despite expensive and elaborative research in finding out mechanisms of interrelation between sleep-disordered breathing (SDB) and stroke, there is yet much attention to be given in stroke units worldwide to the prompt diagnosis and treatment of SDB in order to improve morbidity and mortality rates related with stroke. The preventive diagnosis and treatment of SDB reduce stroke rate and improves penumbra area in case of ischemic stroke. Stroke itself predispose to SDB, making the interrelationship more complicated. The review by Parra O and Arboix A reflects the results from carefully selected reviews reported in the literature so far. This review of the literature and presentation of the original study of the Authors based on their patients' data, enhances the conviction that there exists a direct relation between SDB and stroke. Diagnosis of SDB in new stroke cases should be sought and treated carefully whenever present.

Autologous Skull Bone Flap Sterilization After Decompressive Craniectomy: An Update.

OBJECTIVE: To report new results with ethylene oxide sterilization and new experiences with autogenous bone flaps autoclaved at a high or low temperature for preservation of a bone flap after decompressive craniectomy. METHODS: In 45 patients who underwent a decompressive craniectomy, we determined bone flap preservation with ethylene oxide and with high- or low-temperature autoclave sterilization. RESULTS: The bone flap was repositioned after a mean of 10 weeks in the ethylene oxide group and after 6 weeks in the other sterilization groups. A bone flap infection developed in 1 patient (2%), which required removal and subsequent methyl methacrylate cranioplasty. In 1 child, the bone flap had partially reabsorbed after 12 months. In all other patients, esthetic results were good after an average follow-up of 42 months. At follow-up, computed tomography or magnetic resonance imaging of the bone flap showed preservation of structural features with apparent fusion and revitalization at the bone flap margins. CONCLUSIONS: Ethylene oxide and high- or low-temperature autoclave bone sterilization techniques for the preservation of autologous bone flaps after decompressive craniectomy were safe, rapid, and inexpensive.

Bathing epilepsy: report of three caucasian cases.

INTRODUCTION: Bathing epilepsy is a specific type of reflex epilepsy triggered by domestic bathing in water. It is a geographically specific epilepsy syndrome that is more prevalent in India Cases in Caucasian population are very rarely reported. These cases share many similar clinical features and a similar prognosis to the Indian cases. CASE REPORT: We describe three cases of bathing epilepsy in Albanian population; two cases with well controlled seizures and one with drug-resistant seizures.

Saccular trilobed aneurysm of azygos anterior cerebral artery.

Multiple saccular or giant aneurysms of azygos anterior cerebral artery (AACA) at the distal segments A2-A5 are very rarely reported. Distal anterior cerebral artery (DACA) aneurysms represent approximately 2%-7% of all cerebral aneurysms. We present the case of an Albanian 62-year-old male, admitted at our service after sudden onset of severe headache and vomiting. Computerized tomography (CT) of the head showed hemorrhage in the front of corpus callosum. CT angiography followed by digitally subtracted angiography (DSA) documented a large necked aneurysm with three lobes at the origin of calloso-marginal artery and a single DACA, also known as AACA. A frontal parasagittal craniotomy was performed. Obliteration of the aneurysm was done only by separate clipping of each three lobes at the respective neck. Postoperative DSA demonstrated complete exclusion of the aneurysm and a regular flow of AACA. The patient recovered uneventfully. Despite it is a rare occurrence, an aneurysm of distal segments of anterior cerebral artery A2-A5, concomitant to AACA should be studied with DSA. In the era of embolization, conserving good microsurgical skills is fundamental for dealing with multilobar cerebral aneurysms, associated with rare anatomical variations.

Last call for informed consent: confused proxies in extra-emergency conditions.

Informed consent has become a part of medical practice in Albania only recently, during a time when there has been a substantial increase in claims of malpractice. Its original aim was to provide patients with information to help them make decisions on particular health interventions. We describe the case of a patient who developed an unexpected surgical complication and desperately needed a second intervention, and the futility of obtaining informed consent in the setting of a medical emergency. The circumstances of the emergency might turn out to be too complicated and confusing for the proxies. The, role of proxies is not defined in the Albanian laws and bylaws. Seeking and eventually obtaining the necessary signatures and permissions in an emergency cannot be justified because the lack of time in such circumstances might be a major obstacle to sound and comprehensive communication, and lack of communication could give rise to mistrust, with all its potential consequences.

Spinal Dissemination of Intracranial Glioblastoma in Bevacizumab Era: a Potential Bevacizumab-induced Mechanism.

Spinal metastasis, a devastating neurologic complication of intracranial glioblastomas is not as uncommon as initially thought. It varies from 25% in supratentorial glioblastomas to 60% in infratentorial glioblastomas. The underlying pathogenesis spinal spread of high-grade gliomas is still unclear. To date, no causal responsibility of Bevacizumab (BEV) was noted. Here, we report for the first time, a case of thoracic intramedullary metastases from a cerebral glioblastoma pre-treated with BEV. A critical and exhaustive review is provided.

Case study of a spinal epidural capillary hemangioma: a 4-year postoperative follow-up.

Study Design Case study. Objectives We report the case of a 58-year-old Caucasian man, who presented with a 4-month history of increasing low back pain and gait difficulty. Objective neurologic examination revealed a severe paraparetic symptomatology without any sphincter involvement. Methods Spinal magnetic resonance imaging (MRI) showed an extradural mass formation situated dorsally at the level of thoracic vertebrae T2 to T4. Results A laminectomy was performed with total removal of the mass; histology suggested a highly vascularized lesion with lobular architecture, which seems a very rare case, compatible with a capillary hemangioma. Conclusions A careful follow-up for the next 4 years, including control MRIs every postoperative year, showed a very good neurologic condition of the patient and no recurrence on imaging findings.

Burr hole evacuation for infratentorial subdural empyema.

Infratentorial empyema is a life threatening condition and constitutes a neurosurgical emergency. Purulent mastoiditis and medial otitis is the most common origin and a thorough eradication of the purulent foci is mandatory. Decompression craniectomy has been primarily advised in the literature as the gold standard of the surgical treatment but burr hole evacuation when there the lack of cerebellar edema is less invasive and deemed equally efficient in the few reported cases. This is the report of a seventeen year old female who presented in a comatose state due to infratentorial empyema with acute hydrocephalus and who improved immediately after burr hole evacuation. Details of the surgical procedures are given. Mastoidectomy was completed, with the patient under combined antibiotherapy. She leads a normal life now, more than six years after surgery.

Preservation of the temporal muscle during the frontotemporoparietal approach for decompressive craniectomy: technical note.

BACKGROUND: In patients undergoing decompressive craniectomy, resection and detachment of the temporal muscle produces esthetic and functional damage, due to atrophy of the frontal portion of the temporal muscle in the temporal fossa. We have performed en-block temporal muscle detachment in decompressive craniectomy patients to avoid esthetic and functional damage to the temporal muscle. METHODS: Twenty-one patients underwent decompressive craniectomy using a frontotemporoparietal approach. Through a three-leaf clover flap skin incision, the temporal muscle was detached en-block and overturned antero-inferiorly conjoined with the frontal myocutaneous flap. A decompressive craniectomy and duraplasty were performed. A polyethylene sheet was added to prevent adherence of the temporal muscle to the dura mater. RESULTS: The decompressive craniectomy was effective in all patients. When subsequent cranioplasty was performed, the temporal muscle was easily repositioned. No complications resulted from the en-block temporal muscle detachment or the use of the polyethylene sheet. In 18 patients eligible for clinical and radiological follow-up, excellent (n = 4) or good (n = 14) esthetic results were detected. Chewing ability is considered normal by all patients. CONCLUSION: Although it requires that the patient undergo two surgical procedures, en-block detachment of the temporal muscle during decompressive craniectomy allows good esthetic and functional results.

Saphenous neuropathy due to large hydatid cyst within long adductor muscle: case report and literature review.

An unusual case of saphenous neuropathy secondary to compression by a large hydatid cyst within the adductor longus muscle is reported. Solitary hydatid cyst(s) localized in the skeletal muscles occur rarely and often mimic soft tissue tumours. Presentation with signs of peripheral nerve compression by a hydatid cyst in an extremity is exceedingly rare. Diagnosis can be established by ultrasound, computerized tomography or magnetic resonance if clinically suspected. Clinical suspicion of hydatid origin of a solitary muscle cyst should be high especially in patients hailing from areas endemic for echinococcosis. Laboratory tests are usually unhelpful in such cases and needle biopsy carries the risk of anaphylactic shock and should therefore be avoided. Surgical removal of the unruptured cyst is the treatment of choice in cases of intramuscular hydatid cyst. In the present case, excision of the hydatid cyst was followed by complete clinical recovery. In the absence of systemic involvement, treatment with albendazole may be avoided.

Lumbar hemorrhagic synovial cysts: diagnosis, pathogenesis, and treatment. Report of 3 cases.

BACKGROUND: To define the etiologic, clinical, histological, and surgical features of lumbar hemorrhagic synovial cysts (LHSCs). Three personal cases are reported together with a review of the pertinent literature. METHODS: We identified 3 cases of LHSC treated in our departments and 20 cases culled from the literature. RESULTS: A total of 23 cases of LHSC were selected. All the patients underwent surgical treatment because of untreatable radicular pain and/or neurological deficits. The amount of bleeding, either massive or minor but repeated, influenced the timing of surgery. In our cases, the histological examinations showed an inflammatory reaction within the cyst and the consequent formation of neoangiogenic vessels. CONCLUSIONS: Hemorrhagic synovial cyst of the spine is rare and its most common localization is lumbar. Bleeding within the cyst leads to an increase of its volume, accompanied by neurological deficits and/or painful symptoms that are violent and generally intractable. In this event, surgical excision is the treatment of choice and, in some cases, emergency surgery is necessary. Hemorrhages are probably caused by the rupture of fragile neoangiogenic vessels.