Pneumococcal polysaccharide vaccination administered early after neurotrauma or neurosurgery.

OBJECTIVES: Pneumococcal vaccination is recommended to lower the risk of posttraumatic meningitis, and early vaccination may be of importance. After both trauma and central nervous system injury, immune-suppression may occur, which could affect T-cell function and the response to T-cell dependent vaccines. We therefore aimed to investigate the response to early vaccination with a T-cell independent pneumococcal polysaccharide vaccine (PPSV). METHODS: Thirty-three patients with basilar skull fracture and 23 patients undergoing transsphenoidal pituitary gland surgery were vaccinated with PPSV within 10days after neurotrauma or neurosurgery. Twenty-nine neurosurgical patients vaccinated ⩾3weeks after neurotrauma or neurosurgery served as controls. Serotype-specific anti-polysaccharide binding IgG antibody levels to serotypes 4, 6B, 9V, 14, 18C, 19F and 23F were determined by enzyme immunoassay. RESULTS: The vaccination was safe and a highly significant antibody response was found against all serotypes in all groups (p<0.001 for each of the serotypes). There were no differences between groups or in the group by time interaction in any of the serotypes. After early and late vaccination, protective levels were found in >80% for serotypes 9V, 14, 18C, 19F and 23F and in 70% and 50% for serotypes 6B and 4, respectively. CONCLUSION: Patients vaccinated with PPSV within 10days after neurotrauma or neurosurgery respond similarly to those vaccinated after ⩾3weeks, indicating that PPSV can be administered early after neurotrauma or neurosurgery. CLINICAL TRIALS REGISTRATION: NCT02806284.

Basilar Fracture Due to Frozen Corpse: A Case Report.

Basilar fractures are one of the consequences of craniocerebral injury, which is serious enough to cause death. Legal examiners often pay attention to basilar fractures at autopsy and analyze the relationship between them and death. It is noteworthy whether the fracture is premortem or postmortem. Here, we describe a rarely reported case of basilar fracture due to freezing. In this case, a 30-year-old man was frozen (-18°C) for 6 months after death. At autopsy, external examination showed no trauma. However, on internal examination, there was a basilar fracture which caused controversy but turned out to be a postmortem injury. We provide the case description and discussion on antemortem or postmortem basilar fractures as a differential for these cases.

The anterior interhemispheric approach: a safe and effective approach to anterior skull base lesions.

BACKGROUND: Many approaches to the anterior skull base have been reported. Frequently used are the pterional, the unilateral or bilateral frontobasal, the supraorbital and the frontolateral approach. Recently, endoscopic transnasal approaches have become more popular. The benefits of each approach has to be weighted against its complications and limitations. The aim of this study was to investigate if the anterior interhemispheric approach (AIA) could be a safe and effective alternative approach to tumorous and non-tumorous lesions of the anterior skull base. METHODS: We screened the operative records of all patients with an anterior skull base lesion undergoing transcranial surgery. We have used the AIA in 61 patients. These were exclusively patients with either olfactory groove meningioma (OGM) (n = 43), ethmoidal dural arteriovenous fistula (dAVF) ( n = 6) or frontobasal fractures of the anterior midline with cerebrospinal fluid (CSF) leakage ( n = 12). Patient records were evaluated concerning accessibility of the lesion, realization of surgical aims (complete tumor removal, dAVF obliteration, closure of the dural tear), and approach related complications. RESULTS: The use of the AIA exclusively in OGMs, ethmoidal dAVFs and midline frontobasal fractures indicated that we considered lateralized frontobasal lesions not suitable to be treated successfully. If restricted to these three pathologies, the AIA is highly effective and safe. The surgical aim (complete tumor removal, complete dAVF occlusion, no rhinorrhea) was achieved in all patients. The complication rate was 11.5 % (wound infection (n = 2; 3.2 %), contusion of the genu of the corpus callosum, subdural hygroma, epileptic seizure, anosmia and asymptomatic bleed into the tumor cavity (n = 1 each). Only the contusion of the corpus callosum was directly related to the approach (1.6 %). Olfaction, if present before surgery, was preserved in all patients, except one (1.6 %). CONCLUSIONS: The AIA is an effective and a safe approach to tumorous, vascular and traumatic pathologies of the midline anterior skull base. This approach should be part of the armamentarium of skull base surgeons.

Hyperpneumatization of the skull base: case report.

BACKGROUND AND IMPORTANCE: Temporal bone and skull base pneumatization is a naturally occurring process that begins before birth and continues into early adulthood. Occasionally this process surpasses normal limits, resulting in hyperpneumatization, which is usually obvious, but on rare occasions may mimic more aggressive skull base disorders. An awareness of this rare anatomical variant may help clinicians avoid more extensive investigations. CLINICAL PRESENTATION: We present the case of a 37-year-old man with severe headache and multiple, partially opacified lytic lesions in the skull base noted after minor head trauma. At presentation, a computed tomographic (CT) head scan revealed multiple lucent areas in the skull base after which magnetic resonance imaging (MRI) further suggested the diagnosis of an extensive lytic skull base process associated with a small clival fracture. Needle biopsy revealed nonspecific inflammation. An earlier head CT, not available at the time of admission, demonstrated extensive pneumatized air cells in the basiocciput. During the course of the 2-year follow-up, the originally pneumatized skull base was noted to become permanently opacified with areas of new bone growth. CONCLUSION: We concluded that the skull base abnormality was an anatomical variant associated with a clival fracture and hemorrhage, which led to opacification of the pneumatized air cells. No specific treatment was offered and symptoms resolved completely. Long-term follow-up CT demonstrated opacification of the skull base. This is one of very few cases in the literature reporting the clinical course of a patient with a hyperpneumatized skull base and the subsequent evolution of the disorder after minor head trauma.

Cerebrovascular bypass and aneurysm trapping for the treatment of an A2-segment anterior cerebral artery pseudoaneurysm and herniation through a skull base defect following trauma.

Fractures of the anterior skull base can lead to pseudoaneurysm formation as a result of direct injury to a vessel wall. Pseudoaneurysms in this location are challenging to treat, as both perforator and distal blood supply must be maintained. Additionally, traumatic skull base fractures can lead to a rare condition of cerebral blood vessel herniation through the bony defect, further complicating treatment planning. Treatment of these lesions is essential to (1) prevent the occurrence of potentially fatal subarachnoid hemorrhage and (2) prevent dissection from propagating and compromising blood flow to distal vessels, perforators, and even parent vessels. We present a unique case of a traumatic proximal anterior cerebral artery pseudoaneurysm, herniating through a skull base defect. Treatment consisted of aneurysm trapping and bypass with skull base reconstruction.

Pontomedullary lacerations and concomitant head and neck injuries: their underlying mechanism. A prospective autopsy study.

It is a well-documented fact that pontomedullary lacerations (PML) occur as a result of severe craniocervical injury, but their underlying mechanism has yet to be fully clarified. The aim of this prospective study has been to give greater insight into the underlying mechanism of PML through determining the site of blunt head-impact, as well as the presence of concomitant head and neck injuries in cases of brainstem PML. A total of 56 cases with partial PML have been analysed for this study. The case group was composed of 40 men and 16 women, averaging in age 44.2 ± 19.2 years and consisting of 7 motorcyclists, 4 bicyclists, 18 car occupants, 16 pedestrians, and 10 victims of falls from a height, as well as 1 victim of a fall from standing height. The presented study has shown that there are several possible mechanisms of PML. Impact to the chin, with or without a skull base fracture, most often leads to this fatal injury, due to the impact force transmission either through the jawbone or vertebral column; most likely in combination with a fronto-posterior hyperextension of the head. Additionally, lateral head-impacts with subsequent hinge fractures and PML may also be a possible mechanism. The jawbone and other facial bones are able to act as shock absorbers, and their fracture may diminish the energy transfer towards the skull and protect the brain and brainstem from injury. The upper cervical spine can act as damper and energy absorber as well, and may prevent any occurrence of fracture to the base of the skull.

Traumatic longitudinal clival fracture in a child--case report.

A 7-year-old boy presented with a longitudinal clival fracture following a traffic accident. The boy presented only with temporary unconsciousness despite suffering a fracture of the clivus. Fractures of the clivus are often caused by severe head trauma, and the mortality rate is high due to coexisting injury of the adjacent vessels, brain stem, and lower cranial nerves. Review of the radiological and clinical findings of longitudinal clival fractures found that all reported pediatric patients with longitudinal clival fracture, including the present case, suffered an occipital impact, whereas the majority of longitudinal clival fractures in adults occur following frontal or axial impact.

Endoscopic management of a traumatic meningo-encephalocele through a planum sphenoidale defect: case report.

A 37-year-old man involved in a motor vehicle accident was admitted to our hospital with disturbed consciousness. Computed tomography (CT) showed an acute, right-sided epidural hematoma and pneumocephalus. Emergency evacuation of the acute epidural hematoma was carried out, and his condition gradually recovered. However, cerebrospinal fluid (CSF) rhinorrhea continued despite conservative treatment. Three-dimensional reconstructed CT revealed a bone defect, which was approximately 20 mm in size, in the planum sphenoidale and tuberculum sellae, and magnetic resonance imaging demonstrated a traumatic meningo-encephalocele through the defect, with CSF collection in the sphenoid sinus. Endoscopic endonasal transsphenoidal surgery was performed. The 9-mm diameter dural defect was clearly visualized in the sphenoid sinus and was reconstructed with a combination of suturing and overlay with abdominal fascia, and absorbable polyglycolic acid felt. The CSF leakage from a traumatic meningo-encephalocele through the planum sphenoidale was successfully repaired by endoscopic endonasal surgery. Thorough preoperative evaluation of the feasibilities of the endoscopic and transcranial approaches should be based on the preoperative identification of the fistula, the bone defect, and vital structures.

Post-traumatic peripheral facial nerve palsy: surgical and neuroradiological consideration in five cases of delayed onset.

The facial nerve is frequently injured after head trauma with or without temporal bone fractures. Computed tomography (CT) is the best procedure for detecting the fracture line at the level of the facial nerve canal and for assessing any associated lesions within the temporal bone. Magnetic resonance (MR) is required if there is a facial nerve paralysis, unexplained by CT findings. We present five cases of delayed post-traumatic facial nerve palsy without evidence of temporal bone fractures on CT, thus studied on MR. MR was essential for diagnosing the nerve impairment. Neuroradiological findings, clinical presentation, and electrodiagnostic tests influenced the management of the patients.

Surgical strategy for cerebrospinal fluid rhinorrhea repair.

OBJECTIVE: Cerebrospinal fluid (CSF) rhinorrhea is leakage of CSF from the nasal cavity caused by cranial base or meningeal defects. Surgical treatment of CSF rhinorrhea is still problematic. We evaluated the clinical outcomes of 132 consecutive cases of CSF rhinorrhea treated via transcranial or transnasal endoscopic approaches according to the patient's condition. The indications for the approaches are discussed. METHODS: Of 132 patients with CSF rhinorrhea, a transnasal endoscopic approach was used in 98 to repair cranial base defects in the ethmoid and sphenoid sinuses. A transcranial intradural approach was used in the remaining 34 patients for frontal sinus defects, multiple fractures of the cranial base, or combination nerve injury. RESULTS: CSF rhinorrhea resolved after initial surgery in 124 of 132 patients, giving a success rate of 94%. Of the 8 failures or recurrent cases, 4 were successfully repaired by repeat endoscopic surgery, 2 were cured by transcranial revision surgery, and 2 refused additional surgery (the condition subsequently resolved without treatment in these patients). Postoperative complications included intracranial infection (8 patients) and anosmia (1 patient). No neurological deficits were apparent over the 10-month mean follow-up period. CONCLUSION: Transnasal endoscopic repair is a reliable method for CSF rhinorrhea patients whose fistulae are located in the ethmoid and sphenoid sinuses. The transcranial procedure should be the treatment of choice for patients with frontal sinus fracture, multiple or complex anterior cranial base fractures, or nerve injury. A satisfactory surgical outcome depends on exact diagnosis, proper operative approach, and the surgeon's skill and experience.

Occipital condyle fractures.

OBJECTIVE: The anatomy, clinical presentation, radiologic evaluation, treatment, and outcome of occipital condyle fractures are reviewed. METHODS: We review and discuss the literature on occipital condyle fractures. RESULTS: Occipital condyle fractures are best diagnosed with computed tomography. The neurologic presentation is variable. The majority of these injuries may be treated nonoperatively, but an occipitocervical fusion is necessary to restore stability across the craniovertebral junction. CONCLUSION: Occipital condyle fractures are a rare but serious injury that requires prompt diagnosis and treatment.

Isolated paralysis of glossopharyngeal and vagus nerve associated with type II occipital condyle fracture: case report.

INTRODUCTION: Occipital condyle fractures (OCFs) can occasionally be complicated with lower cranial nerve palsies. DISCUSSION: Isolated 9th and 10th cranial nerve palsies following OCF are very rare. To our knowledge, we report the first case of an early onset of 9th and 10th cranial nerve palsies with an early full recovery in short period of time and discuss the probable mechanism of isolated nerve palsy in the light of the relevant literature.

William Henry Battle and Battle's sign: mastoid ecchymosis as an indicator of basilar skull fracture.

William Henry Battle (1855-1936) practiced medicine in England > 1 century ago and is primarily remembered for his description of ecchymosis over the mastoid, which indicates fracture of the skull base. Although Mr. Battle made many contributions to medicine, almost nothing exists in the literature regarding his life and findings, especially in regard to head injury. The following is a review of Battle's background and his contributions to medicine, specifically his observations associated with basilar skull fractures.

Traumatic aneurysm of the supraclinoid internal carotid artery-case report-.

A 23-year-old male was admitted after a motor vehicle accident with acute epidural hematoma, diffuse subarachnoid hemorrhage (SAH) in the basal cistern, and fractures at the anterior cranial base. Angiography revealed an aneurysm of the right supraclinoid internal carotid artery (ICA). His consciousness suddenly worsened on the 23rd day. Expansion of the SAH in the basal cistern and two hump aneurysms were detected. He underwent endovascular embolization of these aneurysms and the right ICA with Guglielmi detachable coil. Traumatic aneurysms are difficult to diagnose in the early period after injury and are associated with a high mortality. Endovascular treatments for traumatic aneurysms have lower mortality rate, and can be performed under local anesthesia.

Indirect gunshot wound to the head.

BACKGROUND: An Afghani man presented to a U.S. military facility in Afghanistan with a 3-month history of clear fluid from his left naris and frequent sinusitis. Eleven years earlier, he had been struck in the forehead by an object falling from the sky. MATERIALS AND METHODS: Neurologic examination revealed decreased sensation in V1 and V2 on the left side. Imaging revealed a large bullet lodged in the left maxillary sinus. FINDINGS: The bullet was removed via sublabial incision and opening of the anterior bony wall of the maxillary sinus. CONCLUSIONS: In Afghanistan, indirect gunshot wounds to the head are not uncommon because of the constant war conditions since the invasion by the former Soviet Union in 1979 and the tradition of firing rounds into the air during cultural celebrations.