RESOLUTION OF CALVARIAL HYPEROSTOSIS IN AFRICAN LION CUBS (PANTHERA LEO LEO) AFTER VITAMIN A SUPPLEMENTATION.

Two female (FL 1, FL 2) and one male (ML) 11-wk-old, intact, captive African lion cubs (Panthera leo leo) were presented with a history of mild vestibular signs. Initial serum vitamin A concentrations were low (140 nmol/L) for ML. Calvarial hyperostosis was confirmed using computed tomography (CT) of the head and cervical vertebrae in each cub. CT measurements were adapted in relation to the skull width. ML showed the most pronounced thickening of the tentorium cerebelli and occipital bone, represented by a tentorium cerebelli to skull width ratio (TCR) of 0.08 (FL 1: 0.06, FL 2: 0.05) and a basisphenoid to skull width ratio (BBR) of 0.07 (FL 1: 0.06, FL 2: 0.04). Magnetic resonance imaging (MRI) revealed cerebellar herniation and cervical intramedullary T2-weighted hyperintensity from C1, extending caudally for at least two cervical vertebrae in all cubs. Treatment was initiated with subcutaneous vitamin A supplementation and feeding of whole carcasses. Improvement in ataxia was noticed 3 wk later. Follow-up CT and MRI examinations were performed in ML after 3 and 8 mon. The affected bones appeared slightly less thickened and TCR and BBR had decreased to 0.05 after 3 mon. The cerebellum remained mildly herniated, accompanied by amelioration of cervical T2w hyperintensities. After 8 mon, evaluation and diagnostic imaging revealed further improvement regarding the neurologic status and measurements (TCR 0.05, BBR 0.04) despite persistence of a subtle cerebellar herniation. In conclusion, bone remodeling and improvement in clinical signs may be achievable in young lion cubs presented with calvarial hyperostosis and may be attributable to high-dose vitamin A supplementation.

Réplica a «Pápulas faciales en alopecia frontal fibrosante con buena respuesta a isotretinoína» / Reply to «Facial Papules in Frontal Fibrosing Alopecia: Good Response to Isotretinoin»

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Posttraumatic Uncal Herniation in a Conscious Patient.

The incidence of primary traumatic oculomotor nerve palsies in craniocerebral trauma is approximately 1.2% and is usually persistent and associated with loss of consciousness, other neurologic deficits, and skull base or orbital fractures. This case is a rare demonstration of complete left third nerve palsy from uncal herniation after trauma without any loss of consciousness.

Normal saline injection via lumbar puncture for the treatment of acute tonsillar herniation: a report of 45 cases.

OBJECTIVE: Current treatment of apnea attributable to acute tonsillar herniation often is inadequate. This study was undertaken to verify the clinical usefulness of normal saline injection via lumbar puncture for the treatment of apnea secondary to acute tonsillar herniation. METHODS: Between 1969 and 2009, 45 patients who had not regained spontaneous respiratory function after external ventricular drainage or removal of a supratentorial lesion via open craniotomy received an injection of normal saline via lumbar puncture. Patient data were retrospectively analyzed. RESULTS: Eleven of the 45 patients regained spontaneous breathing and recovered fully (24.4%). Sixteen patients regained spontaneous breathing but died later (35.6%), and 18 patients did not regain spontaneous respiration (40.0%). The overall rate of effectiveness of injected normal saline was therefore 60.0%. CONCLUSION: For patients with tonsillar hernia who did not regain spontaneous respiration after external ventricular drainage or removal of a supratentorial lesion, an aggressive approach may be considered. Injection of normal saline via lumbar puncture could improve outcome in some of these patients.

Otitic meningitis, superior semicircular canal dehiscence, and encephalocele: a case series.

BACKGROUND: Otitic meningitis in the postantibiotic era is still a serious condition, requiring intensive treatment and prolonged rehabilitation. In view of the significant morbidity and mortality rate, conditions that may increase the likelihood of otitic meningitis developing should be treated promptly. The incidence of meningitis after asymptomatic encephaloceles of the middle cranial fossa varies greatly, and the management differs between elective surgical repair and expectant careful observation. Superior semicircular canal dehiscences (SSCDs) are postulated to have a congenital origin and are associated with a thin or dehiscent tegmen. Several cases of simultaneous SCCD and tegmen defects have been reported, but the findings of otitic meningitis, SCCD, and encephaloceles has, to the best of our knowledge, not been previously explored in the literature. METHODS: We reviewed a series of 4 patients who all presented with a combination of otitic meningitis, encephaloceles, and SSCD. RESULTS: All the 4 patients we reviewed had meningitis secondary to otitis media with computed tomographic scans confirming the presence of SCCD with ipsilateral tegmen tympani defects and associated cephaloceles. All patients were treated with intravenous antibiotics and underwent surgery that ranged from myringotomy and ventilation tube insertions, mastoidectomy, and burr hole drainage for temporal lobe abscess. They were all associated with intensive care unit admission, significant morbidity, and prolonged hospital stays. There were no mortalities. CONCLUSION: We propose that in all SSCD patients, a careful computed tomographic examination of the cranial base should be undertaken to exclude other associated tegmen tympani defects. In cases of SSCD requiring surgery, we support the view that elective surgical repair be recommended where asymptomatic ipsilateral encephaloceles are found, to reduce the risk of otitic meningitis.

Estimulación de nervio periférico en el tratamiento de diferentes tipo de cefaleas / Peripheral nerve stimulation in the treatment of various types of headache

Introducción. La cefalea constituye una enfermedad con gran impacto en la calidad de vida y la economía de los países industriales. Una de las teorías fisiopatológicas se encuentra la activación de las fibras aferentes cervicales de los nervios C2-C3. La neuroestimulación periférica aferente de C2-C3, que se provoca en la estimulación del nervio occipital, parece aliviar la cefalea a través de las conexiones trigeminocervicales, y ser una de las causas principales de su eficacia. Material y métodos. Estudio multicéntrico retrospectivo entre abril 2005 y mayo 2009. Se incluyó a los pacientes con cefalea crónica mayor que fueron tratados con neuroestimulación. En todos los pacientes se valoró el tipo de cefalea, el grado de dolor mediante una escala numérica simple, tratamiento médico y episodios de cefalea. Se analizó el porcentaje de test negativos. En los portadores del generador definitivo se valoró la eficacia de la técnica mediante el análisis de la escala numérica simple y el análisis del porcentaje de mejoría subjetiva de los pacientes al mes, 3 meses, 6 meses y 12 meses. Se analizó el grado de cobertura, la satisfacción, la disminución de los episodios y la medicación y las complicaciones. Resultados. Se incluyeron 31 pacientes. El resultado del test fue positivo en el 87%. Existió una disminución significativa (p < 0,001) del dolor desde el momento basal con una mejoría mayor del 50% sostenido del 85,2% y un descenso en la puntuación de la escala numérica simple > 2 puntos en un 96,3% de los casos. Todos los pacientes estaban satisfechos durante el estudio. El 56% de la muestra no tuvo episodios de cefaleas tras el año de estudio y el 47% dejo de tomar medicación. La complicación más frecuente fue la migración del electrodo (AU)

Background and objective. Headache has a great impact on patients quality of life and in industrialized countries there is economic impact as well. One of the pathophysiologic theories to explain headache is activation of afferent C2-C3 nerve fibers. Afferent peripheral nerve stimulation by occipital nerve provocation at C2-C3 seems to alleviate headache by acting on the trigeminocervical complex, which would largely explain the effectiveness of this modality. The aim of this study was to describe peripheral nerve stimulation as an alternative therapy in patients who do not respond to other headache treatments. Material and methods. Multicenter retrospective study between April 2005 and May 2009, analyzing cases of patients treated with nerve stimulation for severe chronic headache. In all patients the medical history included type of headache, intensity of pain on a numerical scale, medical treatment used, and number of headache episodes. We recorded the percentage of patients with negative tests. Patients implanted with a generator assessed effectiveness on the numerical scale; we analyzed the percentage of perceived improvement at 1, 3, 6, and 12 months. We also analyzed the extent of coverage provided by the electrodes, patient satisfaction, reduction in the number of episodes and medication, and complications. Results. Of 31 patients, 87% had positive results, with a significant decrease in pain from baseline (P <. 001); 85.2% reported sustained improvement of >50%, and 96.3% reported a decrease of > 2 points on the pain scale. All patients expressed satisfaction during the period of follow-up. Fifty-six percent had no headaches after a year and 47% had stopped taking medication. The most frequent complication was electrode migration (AU)

[Electrophysiologial evaluation of ozone in treating of lumbar disc herniation with curving sheath-needle multi-direction rotating injection].

OBJECTIVE: To compare electrophysiological changes in treating lumbar disc herniation (LDH) with ozone by curving sheath-needle multi-direction rotating injection (CSNMRI) and conventional injection method. METHODS: From May 2005 to June 2009,100 patients with LDH were studied, included 68 males and 32 females, ranging in age from 25 to 58 years with an average of 44 years, in course of disease from 3 months to 8 years with an average of 8.8 months. All patients were numbered according to sequence of visit, and were completely randomly divided into group A and group B with DPS software, 50 cases in each group. All patients were injected ozone into lesion of intervertebral disc, in group A with CSNMRI and in group B with conventional method. The electrophysiologic study of all patients was performed respectively before treatment and at the 3 month after treatment. The electromyogram (EMG) of the main muscle groups of involved lower limb and the corresponding segments of sacrospinal muscle was tested; the duration and multiphase-wave rate of MUP were calculated. H-reflex of tibial nerve in both lower limbs was observed and the number of abnormal H-reflex and the H-wave latency were recorded. RESULTS: After treatment, the number of muscles with abnormal EMG was reduced to different degrees in each group, but there was more significant reduction in group A (P < 0.05 or 0.01); the duration and multiphase-wave rate of MUP in the two groups were both reduced and close to the normal level (P < 0.01), yet the changes in group A was more than that of group B (P < 0.05 or 0.01). There was no significant difference in the number of abnormal H-reflex before treatment between two groups, whereas was markedly lower in group A than that of group B after treatment (P < 0.05). After treatment, H-wave latency in two groups was shortened and become close to normal, but group B was more statistically significant than group B (P < 0.05). CONCLUSION: The neural electrophysiological abnormalities can reflect the degree of nerve root compression and damage, and is one of the objective indicators to estimate neuromuscular function. It can better meliorate abnormal electrophysiology to inject ozone to treat LDH with CSNMRI than conventional method.

Acute cerebellitis presenting as tonsillar herniation and hydrocephalus.

Acute cerebellitis is a rare inflammatory syndrome, often characterized by cerebellar dysfunction of rapid onset. We describe two children, a girl aged 5 years and a boy aged 11 years, with acute cerebellitis. Both manifested tonsillar herniation and hydrocephalus. The cause was Mycoplasma pneumoniae infection in the first patient, and unknown in the second. The girl was treated conservatively with steroids and diuretics, as well as vibramycin, and the boy required insertion of a ventriculostomy. Both presented a good prognosis and full recovery.

Acquired encephalocele attributable to tuberculous osteitis: case report.

OBJECTIVE: There are many forms of calvarial tuberculosis. In this case report, extensive calvarial tuberculosis caused a large cranial defect and occlusion of the sigmoid sinus in a 10-year-old child. This resulted in a transient increase of the intracranial pressure and formation of an acquired encephalocele. CLINICAL PRESENTATION: A 10-year-old boy presented with an acquired, infected encephalocele and features of tuberculous mastoiditis. Computed tomographic and magnetic resonance imaging scans demonstrated evidence of left occipital encephalocele with left mastoiditis, extradural granulations, bone destruction, and complete occlusion of the left sigmoid sinus. INTERVENTION: The encephalocele was surgically excised and combined with left mastoidectomy. Although no mycobacterium had been demonstrated in the excised lesion, the presence of active tuberculous infection in the mastoid led to the conclusion that the bone destruction leading to encephalocele was secondary to the calvarial tuberculosis. The patient received antituberculous treatment with clinical improvement. CONCLUSION: This is the first report of calvarial tuberculosis causing a cranial defect and venous sinus thrombosis and resulting in an acquired encephalocele. Surgical excision combined with medical treatment was curative.

Clinical use of lidocaine for control of stroke oedema in the posterior cranial fossa accompanied by acute hydrocephalus.

Intravenous Lidocaine, in combination with steroid and Mannitol was used in 17 critical cases to control posterior fossa stroke oedema with jeopardised upward or downward herniation. Lidocaine successfully provided time for observation to select 5 correct candidates out of 17, indicated for aggressive decompression surgery in addition to ventricular drainage for acute hydrocephalus. There is no 'Golden-Rule' for this situation but the use of Lidocaine has a place in the management of it.

Prediction and evaluation of brainstem function by auditory brainstem responses in patients with uncal herniation.

Serial measurements of auditory brainstem-evoked responses (BERs) were conducted in 15 patients with supratentorial mass lesions. Significant prolongation of the latency of wave V BERs, which originates in the inferior colliculus, occurred when the intracranial pressure (ICP) approached 30 mmHg. In four of five patients whose BERs were measured before pupillary changes, a significant lengthening of wave V latency was observed prior to clinical manifestation of uncal herniation. These results suggest that immediate medical or surgical decompression of ICP should be performed when ICP approaches 30 mmHg with significant prolongation of wave V latency.