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1.
Neurocirugía (Soc. Luso-Esp. Neurocir.) ; 34(1): 32-39, ene.-feb. 2023. ilus, tab
Artigo em Inglês | IBECS | ID: ibc-214411

RESUMO

Craniopharyngiomas are benign epithelial tumors which may very occasionally recur in ectopic locations. We present two cases of ectopic recurrence, both in the posterior fossa, and provide a review of the literature with basic statistics. Two patients admitted to our institution with posterior fossa lesions underwent gross total resection. Pathological studies showed adamantinomatous craniopharyngiomas (ACP). Both patients had a prior history of suprasellar tumor surgery. We also reviewed the related data and undertook a basic statistical analysis. We found 67 cases of ectopic recurrent craniopharyngioma (including the present cases): 51 cases were adamantinomatous (76%), 6 papillary (9%) and 10 unknown (15%). 18 cases occurred in the posterior fossa, all of them diagnosed as the ACP subtype. The intervals until recurrence were 15.15 years for posterior fossa recurrences and 5.75 years for supratentorial cases. Student t test showed significant differences in time to recurrence (p 0.002). Gross total resection was performed in 53 cases (79%), subtotal resection + radiotherapy in 3 (5%) and 11 (16%) cases were treated with other options. Ectopic recurrence is a rare but possible event. Those in the posterior fossa may appear later than in the supratentorial space. ACP is likely to be the most common subtype in these cases, possibly due to its more aggressive behavior compared to the papillary subtype. Long term follow-up should be performed to detect ectopic recurrences. Ectopic recurrences are often surgically accessible and gross total resection should be achieved. (AU)


Los craneofaringiomas son tumores epiteliales benignos que pueden recurrir ocasionalmente en localizaciones ectópicas. Presentamos 2 casos de recurrencias ectópicas, ambos en fosa posterior, y realizamos una revisión de la literatura con análisis estadístico básico. Dos pacientes ingresaron en nuestro servicio con lesiones en fosa posterior en quienes se indicó resección quirúrgica. El diagnóstico histopatológico fue de craneofaringioma adamantinomatoso en ambos casos. Ambos pacientes fueron intervenidos años atrás por un tumor supraselar. Se hallaron 67 casos descritos de recurrencia ectópica de craneofaringioma (incluyendo el presente estudio): 51 fueron adamantinomatoso (76%), 6 papilar (9%) y 10 desconocidos (15%). Dieciocho casos ocurrieron en la fosa posterior, todos con diagnóstico de craneofaringioma adamantinomatoso. El intervalo hasta la recurrencia fue de 15,15 años para aquellas en la fosa posterior y de 5,75 años para recurrencias supratentoriales. El test de Student mostró diferencias estadísticamente significativas en el tiempo de recurrencia (p 0,002). En 53 casos se obtuvo una resección completa (79%), resección subtotal + radioterapia en 3 (5%) y 11 casos se usaron otras modalidades de tratamiento (16%). La recurrencia ectópica es un evento raro, pero posible. Aquellas en la fosa posterior pueden aparecer más tarde que a nivel supratentorial. Los craneofaringiomas adamantinomatosos son los subtipos más probables en esos casos, posiblemente debido a su comportamiento más agresivo comparado con los papilares. Un seguimiento a largo plazo debe llevarse a cabo para detectar dichas recurrencias ectópicas, ya que estas suelen ser quirúrgicamente accesibles, y debe obtenerse una resección completa. (AU)


Assuntos
Humanos , Masculino , Adulto , Neoplasias Encefálicas/diagnóstico por imagem , Neoplasias Encefálicas/cirurgia , Craniofaringioma/diagnóstico por imagem , Craniofaringioma/cirurgia , Recidiva Local de Neoplasia , Fossa Craniana Posterior
4.
Oper Neurosurg (Hagerstown) ; 23(5): 396-405, 2022 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-36103356

RESUMO

BACKGROUND: Large, destructive intracranial and extracranial lesions at the jugular foramen (JF) and anterior craniovertebral junction (CVJ) are among the most challenging lesions to resect. OBJECTIVE: To compare the extreme lateral transodontoid approach (ELTOA) with the extreme medial endoscopic endonasal approach (EMEEA) to determine the most effective surgical approach to the JF and CVJ. METHODS: Seven formalin-fixed cadaveric heads were dissected. Using neuronavigation, we quantitatively measured and compared the exposure of the intracranial and extracranial neurovascular structures, the drilled area of the clivus and the C1 vertebra, and the area of exposure of the brainstem. RESULTS: The mean total drilled area of the clivus was greater with the EMEEA than with the ELTOA (1043.5 vs 909.4 mm 2 , P = .02). The EMEEA provided a longer exposure of the extracranial cranial nerves (CNs) IX, X, and XI compared with the ELTOA (cranial nerve [CN] IX: 18.8 vs 12.0 mm, P = .01; CN X: 19.2 vs 10.4 mm, P = .003; and CN XI, 18.1 vs 11.9 mm, P = .04). The EMEEA, compared with the ELTOA, provided a significantly greater area of exposure of the contralateral ventromedial medulla (289.5 vs 80.9 mm 2 , P < .001) and pons (237.5 vs 86.2 mm 2 , P = .005) but less area of exposure of the ipsilateral dorsolateral medulla (51.5 vs 205.8 mm 2 , P = .008). CONCLUSION: The EMEEA and ELTOA provide optimal exposures to different aspects of the CVJ and JF. A combination of these approaches can compensate for their disadvantages and achieve significant exposure.


Assuntos
Forâmen Jugular , Fossa Craniana Posterior/cirurgia , Endoscopia , Formaldeído , Humanos , Nariz/cirurgia
5.
World Neurosurg ; 166: e841-e849, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-35948218

RESUMO

OBJECTIVE: The anterior petrosectomy, also known as the Kawase approach, and the retrosigmoid intradural suprameatal approach (RISA) have both been used to reduce the petrous apex and access the petroclival region. Our goal was to compare the volumes and 3-dimensional shapes of bony resection obtained through each approach while trying to resemble realistic surgical settings. METHODS: Five cadaveric specimens totaling 10 sides were dissected and analyzed. In every specimen, 1 side was used for the Kawase approach while the opposite side was used for the RISA. Petrosectomy volumes were assessed by comparing preoperative and postoperative thin-sliced computed tomography scans. RESULTS: Petrosectomy volumes were significantly larger through the Kawase approach than through the RISA (0.82 ± 0.11 vs. 0.49 ± 0.07 cm3, P < 0.001). In addition, surgical maneuverability and freedom were greater in the Kawase operative variant. Lastly, the morphology of the bony window achieved through each approach was clearly different: trapezoid for the anterior petrosectomy versus elongated ellipsoid for the RISA. CONCLUSIONS: The Kawase approach invariably results in larger volumes of bony removal than the RISA operative variant, and the volume of petrosectomy that is spatially congruent is only partially identical. The Kawase corridor is best suited for middle fossa lesions that extend into the posterior fossa, while the RISA is suitable for pathologies mainly residing in the posterior fossa and extending into the Meckel cave.


Assuntos
Procedimentos Neurocirúrgicos , Osso Petroso , Cadáver , Fossa Craniana Posterior/anatomia & histologia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgia , Craniotomia , Humanos , Procedimentos Neurocirúrgicos/métodos , Osso Petroso/anatomia & histologia , Osso Petroso/diagnóstico por imagem , Osso Petroso/cirurgia , Tomografia Computadorizada por Raios X
6.
Neurol Med Chir (Tokyo) ; 62(9): 400-415, 2022 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-36031349

RESUMO

We investigated the mechanism underlying Chiari malformation type I (CM-I) and classified it according to the morphometric analyses of posterior cranial fossa (PCF) and craniocervical junction (CCJ). Three independent subtypes of CM-I were confirmed (CM-I types A, B, and C) for 484 cases and 150 normal volunteers by multiple analyses. CM-I type A had normal volume of PCF (VPCF) and occipital bone size. Type B had normal VPCF and small volume of the area surrounding the foramen magnum (VAFM) and occipital bone size. Type C had small VPCF, VAFM, and occipital bone size. Morphometric analyses during craniocervical traction test demonstrated instability of CCJ. Foramen magnum decompression (FMD) was performed in 302 cases. Expansive suboccipital cranioplasty (ESCP) was performed in 102 cases. Craniocervical posterolateral fixation (CCF) was performed for CCJ instability in 70 cases. Both ESCP and FMD showed a high improvement rate of neurological symptoms and signs (84.4%) and a high recovery rate of the Japanese Orthopaedic Association (JOA) score (58.5%). CCF also showed a high recovery rate of the JOA score (69.7%), with successful joint stabilization (84.3%). CM-I type A was associated with other mechanisms that caused ptosis of the brainstem and cerebellum (CCJ instability and traction and pressure dissociation between the intracranial cavity and spinal canal cavity), whereas CM-I types B and C demonstrated underdevelopment of the occipital bone. For CM-I types B and C, PCF decompression should be performed, whereas for small VPCF, ESCP should be performed. CCF for CCJ instability (including CM-I type A) was safe and effective.


Assuntos
Malformação de Arnold-Chiari , Malformação de Arnold-Chiari/complicações , Malformação de Arnold-Chiari/diagnóstico por imagem , Malformação de Arnold-Chiari/cirurgia , Fossa Craniana Posterior/patologia , Descompressão Cirúrgica , Humanos , Imageamento por Ressonância Magnética
7.
Pediatr Neurosurg ; 57(5): 358-364, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35988537

RESUMO

INTRODUCTION: Intradiploic pseudomeningoceles, also called intradiploic cerebrospinal fluid (CSF) fistulas, are abnormal CSF collections between the two bony tables of the calvaria resulting from postsurgical CSF leakage. To date, only six cases of intradiploic pseudomeningocele have been reported, all occurring in the occipital area. In this paper, we report the seventh case of late-onset occipital intradiploic pseudomeningocele (OIP) occurring in a young female patient who underwent surgery for the removal of a cerebellar pilocytic astrocytoma. In this regard, we also review the literature on the few recognized cases of OIP. CASE PRESENTATION: The case of an 18-year-old female patient known to our institute for an operation 12 years earlier to remove a pilocytic astrocytoma is illustrated. At admission, the patient complained only of occasional orthostatic headache. Brain imaging demonstrated a pseudomeningocele extended intradiploically from the occipital squama to the condylar and clivus regions, thinning both occipital bone tables and dilating the CSF-filled diploe. Watertight duroplasty and cranioplasty were effectively performed. CONCLUSION: Pediatric patients undergoing posterior cranial fossa craniotomy/craniectomy may postoperatively develop OIP. In this setting, treatment of any dural CSF fistula should be considered because of the risk of progressive extension and bone erosion.


Assuntos
Astrocitoma , Fossa Craniana Posterior , Humanos , Feminino , Criança , Adolescente , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgia , Vazamento de Líquido Cefalorraquidiano/etiologia , Osso Occipital/diagnóstico por imagem , Osso Occipital/cirurgia , Craniotomia/efeitos adversos , Craniotomia/métodos , Astrocitoma/cirurgia , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia
8.
J Neurooncol ; 159(3): 627-635, 2022 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-35972674

RESUMO

INTRODUCTION: Clival malignancies pose particular surgical challenges due to complex skull base anatomy and the involvement of vital neurovascular structures. While endoscopic endonasal approached are widely used, the outcomes for clival malignancies remain poorly understood. In this study we assessed the impact of endoscopic and open surgical approaches on PFS, time to initiation of radiotherapy, KPS, and GTR rates for clival malignancies. METHODS: A retrospective case series for clival malignancies operated between 1993 and 2019 was conducted. Inclusion criteria were age over 18 and a follow-up of at least a 6 months. Statistical analyses were conducted using STATA version 15 statistical software package StataCorp. RESULTS: For the whole cohort (113 patients), and for upper and middle lesions, open surgical approaches increased odds of disease progression, compared to EEA (HR 2.10 to HR 2.43), p < 0.05. EEA had a shorter time interval from surgery to initiation of radiotherapy. No difference in 6 and 12 month KPS was found between surgical groups. Patients undergoing open surgery were less likely to achieve GTR for upper clival lesions. CONCLUSIONS: EEA was found to be associated with increased PFS, for upper and middle clival malignancies. The time to initiation of radiotherapy was shorter for patients undergoing EEA compared to open surgery for patients with middle clival involvement. GTR rates were found to be significantly better with EEA for patients with upper clival malignancies.


Assuntos
Cordoma , Neoplasias da Base do Crânio , Cordoma/cirurgia , Fossa Craniana Posterior/cirurgia , Humanos , Lactente , Estudos Retrospectivos , Base do Crânio , Neoplasias da Base do Crânio/cirurgia
10.
Surg Radiol Anat ; 44(8): 1147-1156, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35871409

RESUMO

INTRODUCTION: We hypothesized that the cranial phenotype influences the shape of the posterior cranial fossa and the relative position of the sigmoid sinus. MATERIALS AND METHODS: The topography of the sigmoid sinus was studied on 26 magnetic resonance venograms and 35 embalmed cadavers by morphometric analysis, dissection, and photo modeling techniques. RESULTS: The data show that the transverse diameter of the posterior cranial fossa correlates positively with the laterolateral diameter of the skull. The majority of cases with the low-anterior position of the sigmoid sinus were recorded in the brachycephalic group (82%), while the high-posterior localization of the sigmoid sinus was typical for the dolichocephalic patients (63%). The results of the ANOVA test confirm the significance of differences. CONCLUSIONS: The shape of the skull reflects the morphology of the posterior cranial fossa and influences the topographic characteristics of the sigmoid sinus that must be considered in the selection of surgical approach to the inner ear and pontocerebellar angle.


Assuntos
Cavidades Cranianas , Fossa Craniana Posterior/anatomia & histologia , Fossa Craniana Posterior/diagnóstico por imagem , Cavidades Cranianas/diagnóstico por imagem , Cavidades Cranianas/cirurgia , Humanos , Procedimentos Neurocirúrgicos/métodos , Fenótipo
11.
Ulus Travma Acil Cerrahi Derg ; 28(7): 997-1007, 2022 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-35775670

RESUMO

BACKGROUND: The aim of this study is to contribute to the literature by determining the morphometric reference values of the bony structures in the craniovertebral junction (CVJ) from computer tomography (CT) images of the pediatric age group. METHODS: In this study, CT's of 151 simple trauma patients aged between 3 and 15 years between 2016 and 2020 were evaluated. All CT examinations were performed using a 32-slice CT and included images of the skull base and C1-C2 junction. A total of 10 measurements were obtained from these images, including Wachenheim clivus canal angle (WCA), Welcher basal angle (WBA), Cran-iocervical tilt angle (CCT), power ratio (PR), Atlantodens interval, McRae Line (MRL), McRae - Dens distance, basion-dens interval (BDI), basion-axis interval (BAI), and atlantooccipital measurement (AOM). RESULTS: In comparison between gender groups, MRL (p=0.011) and AOM (p<0.001) measurements were found to be significantly higher in males. McRae-Dens distance, BDI, and AOM were significantly higher in patients aged 3-9 years (respectively, p=0005, p=0.003, p<0.001), and BAI (p=0.001) was significantly higher in patients aged 10-15 years. The McRae - Dens distance (p=0.119) was similar between patients with and without terminal ossicle in odontoid apex. But BDI of patients without terminal ossicle was significantly higher (p=0.048). All parameters, except the WCA, WBA, CCT, and PR, were statistically significantly correlated with the patient age (respectively, p=0.21, p=0.13, p=0.70, p=0.99). CONCLUSION: In this study, the morphometric reference values of the bone structures at the CVJ were determined from the CT images of the pediatric age group.


Assuntos
Cabeça , Tomografia Computadorizada por Raios X , Adolescente , Criança , Pré-Escolar , Fossa Craniana Posterior , Humanos , Masculino , Exame Físico
14.
J Clin Ultrasound ; 50(9): 1312-1319, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-35730722

RESUMO

Antenatal posterior fossa cystic lesions are intimidating due to overlapping imaging features of benign and severe malformations. Sonographic assessment of the posterior fossa with good resolution median sagittal and axial views, either primary or secondarily reconstructed, plays the lead role in antenatal evaluation, further enhanced when sequential assessments are added. We present 10 cases of fetal posterior fossa cystic lesions diagnosed in the first and second trimesters that were sequentially analyzed and followed up till delivery or termination. The ultrasound imaging appearance, evolution, and morphometry have been presented in this article.


Assuntos
Cistos , Síndrome de Dandy-Walker , Humanos , Feminino , Gravidez , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/anormalidades , Fossa Craniana Posterior/patologia , Segundo Trimestre da Gravidez , Feto/patologia , Cistos/patologia , Imageamento por Ressonância Magnética/métodos
15.
No Shinkei Geka ; 50(3): 525-534, 2022 May.
Artigo em Japonês | MEDLINE | ID: mdl-35670165

RESUMO

The posterior fossa is a site where blood vessels and nerves are very dense, so surgery can be very difficult. Therefore, serious sequelae may occur due to complications. Surgeons should be familiar with the complex anatomy of the posterior fossa. This paper outlines the anatomy of the bone, brain, and nerves involved in the surgical approach from the lateral posterior to the cerebellar pontine angle and foramen magnum.


Assuntos
Cerebelo , Forame Magno , Encéfalo , Fossa Craniana Posterior/cirurgia , Forame Magno/cirurgia , Humanos , Ponte
16.
No Shinkei Geka ; 50(3): 625-633, 2022 May.
Artigo em Japonês | MEDLINE | ID: mdl-35670176

RESUMO

The lateral suboccipital retrosigmoid approach is one of the most established approaches for accessing the posterior cranial fossa. In order to expand the surgical field, several extensions, including(1)extended craniotomy(e.g., far lateral, transcondylar, and transsigmoid approaches), (2)additional intradural osseous or bony drilling(e.g., transmeatal and suprajugular approaches), and (3)fissure dissection(e.g., suprafloccular and infrafloccular approaches), have been described. In this report, we introduce our technique for the retrosigmoid approach and review several extensions as illustrated by schwannoma, meningioma, and epidermoid cyst surgeries.


Assuntos
Cisto Epidérmico , Neoplasias Meníngeas , Meningioma , Neurilemoma , Fossa Craniana Posterior/cirurgia , Cisto Epidérmico/cirurgia , Humanos , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Neurilemoma/cirurgia
17.
Neuroradiology ; 64(8): 1483-1509, 2022 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-35657394

RESUMO

The sphenoid bone is an unpaired bone that contributes to the formation of the skull base. Despite the enormous progress in transnasal endoscopic visualisation, imaging techniques remain the cornerstones to characterise any pathological condition arising in this area. In the present review, we offer a bird's-eye view of the developmental, inflammatory, and neoplastic alterations affecting the sphenoid body and clivus, with the aim to propose a practical diagnostic aid for radiologists based on clinico-epidemiological, computed tomography, and magnetic resonance imaging features.


Assuntos
Fossa Craniana Posterior , Base do Crânio , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/patologia , Humanos , Imageamento por Ressonância Magnética/métodos , Osso Esfenoide/diagnóstico por imagem , Osso Esfenoide/patologia , Tomografia Computadorizada por Raios X/métodos
18.
Artigo em Russo | MEDLINE | ID: mdl-35758082

RESUMO

The authors present a patient and neurosurgical nuances of total resection of recurrent meningioma of posterior surface of petrous bone 65´35´30 mm. The tumor captured two critical zones of posterior cranial fossa with unusual frontal growth and spread from the surface of petrous bone to the fourth ventricle. The neoplasm filled the ventricle without lesion of ependyma. Extensive fibrous meningioma of posterior surface of petrous bone was totally excised 18 years ago. MRI was annually carried out for 5 years. Surgical nuances that ensured total extraction of tumor without cytoreduction were as follows: 1) en-bloc resection of tumor from the fourth ventricle due to smooth surface of tumor and minimum number of adhesions with cerebellum; MR-confirmed CSF strip between the tumor edges and walls of the ventricle; no signs of hydrocephalus in subtotal ventricular tamponade; 2) unusual frontal tumor growth under 45º required appropriate angular traction of tumor with minimal rotation; 3) traction was followed by sequential appearance of 3 segments of tumor: petrous, apertural and ventricular; 4) topography of the area of lateral eversion of the fourth ventricle was established by identifying the narrowing (constriction) of tumor; 5) in extracting the tumor from the fourth ventricle, we performed minimal rotation to avoid damage to ventricular walls and lateral aperture due to difference between the larger and smaller diameters (by 6 mm) of ovoid ventricular segment of tumor; 6) no CSF leakage following appearance of ventricular segment (tumor enlargement) indicated integrity of ependyma of the fourth ventricle. Histological examination confirmed fibrous meningioma. Fast and complete regression of focal symptoms was observed after surgery. A 3-year follow-up after surgery revealed no signs of tumor recurrence.


Assuntos
Neoplasias Meníngeas , Meningioma , Fossa Craniana Posterior/patologia , Quarto Ventrículo/diagnóstico por imagem , Quarto Ventrículo/cirurgia , Humanos , Neoplasias Meníngeas/diagnóstico por imagem , Neoplasias Meníngeas/patologia , Neoplasias Meníngeas/cirurgia , Meningioma/diagnóstico por imagem , Meningioma/patologia , Meningioma/cirurgia , Procedimentos Neurocirúrgicos , Osso Petroso/patologia , Osso Petroso/cirurgia
19.
Acta Neurochir (Wien) ; 164(11): 2819-2832, 2022 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-35752738

RESUMO

BACKGROUND: Transpetrosal approaches are technically complex and require a complete understanding of surgical and radiological anatomy. A careful evaluation of pre-operative magnetic resonance imaging and computed tomography scan is mandatory, because anatomical or pathological variations are common and may increase the risk of complications related with the approach. METHODS: Pre-operative characteristics of venous and petrous bone anatomy were analysed and correlated with intraoperative findings, using injected magnetic resonance imaging and thin-slices computed tomography scan. These data regularly checked before each transpetrosal approach were progressively included in the presented checklist. RESULTS: Transpetrosal approaches have been used in 101 patients. Items included in the checklist were petrous bone pneumatization, angle between petrous apex and clivus, dehiscence of petrous carotid artery, dehiscence of geniculate ganglion, distance between superior semicircular canal and middle fossa floor, distance between cochlea and middle fossa floor, sigmoid sinus dominance, transverse sigmoid sinus junction depth to the outer cortical bone, jugular bulb height (high or low), location of the vein of Labbé, characteristics of superior petrosal vein complex. CONCLUSION: The presented checklist provides a systematic scheme of consultation of characteristic of venous and petrous bone anatomy for transpetrosal approaches. In our experience, the use of this checklist reduces the risk of complications related with approach, by minimizing the neglect of crucial information.


Assuntos
Lista de Checagem , Osso Petroso , Humanos , Osso Petroso/diagnóstico por imagem , Osso Petroso/cirurgia , Osso Petroso/anatomia & histologia , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgia , Cavidades Cranianas , Hospitais
20.
Can J Anaesth ; 69(7): 900-906, 2022 07.
Artigo em Inglês | MEDLINE | ID: mdl-35585474

RESUMO

PURPOSE: Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines. CLINICAL FEATURES: We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression. CONCLUSIONS: Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.


RéSUMé: OBJECTIF: Dans de nombreux pays, la mort cérébrale / décès déterminé par des critères neurologiques (MC / DDN) peut être déterminée par un examen clinique qui montre le coma, l'aréflexie du tronc cérébral et l'apnée, sous réserve que les conditions causant une perte réversible de la fonction cérébrale soient exclues a priori. À ce jour, les comptes rendus décrivant un rétablissement après une MC / DDN chez les adultes ont été limités en raison d'un non-respect des lignes directrices. CARACTéRISTIQUES CLINIQUES: Nous rapportons le cas d'un homme de 72 ans atteint d'une lésion cérébrale sous-tentorielle primaire (hémorragique) et secondaire globale (anoxique) chez qui une craniectomie décompressive de la fosse postérieure et une hypothermie thérapeutique de six heures (33-34 °C), suivie d'un réchauffement de 8 heures à ≥ 36 °C, ont été réalisés. Treize heures plus tard, les résultats cliniques de la perte de la fonction cérébrale ont été documentés, en plus de l'exclusion conforme aux lignes directrices des causes réversibles (hypotension artérielle, intoxication, effets des médicaments dépresseurs, déséquilibre métabolique ou endocrinien pertinent, hypercapnie chronique, troubles neuromusculaires et administration d'un relaxant musculaire). Étant donné qu'une lésion cérébrale sous-tentorielle primaire était présente, les directives allemandes exigeaient la réalisation d'autres tests auxiliaires. L'échographie Doppler a révélé la préservation d'une certaine circulation cérébrale, et la MC / DDN n'a pas été diagnostiquée. Environ 24 heures après le réchauffement du patient à ≥ 36 °C, le patient a manifesté des efforts respiratoires. Il a continué à respirer avec assistance jusqu'à l'asystole / l'apnée finale, sans retrouver de fonction cérébrale supplémentaire autre que de légers signes d'hémispasticité. La tomodensitométrie de suivi a montré une hernie partielle du cervelet à travers l'espace de craniectomie de la fosse postérieure, soulageant la compression caudale du tronc cérébral. CONCLUSION: La craniectomie décompressive thérapeutique de la fosse postérieure peut permettre une inversion retardée de l'apnée. Chez ces patients, la preuve d'un arrêt circulatoire cérébral devrait être obligatoire pour diagnostiquer une MC / DDN.


Assuntos
Morte Encefálica , Fossa Craniana Posterior , Craniectomia Descompressiva , Idoso , Morte Encefálica/diagnóstico , Fossa Craniana Posterior/cirurgia , Humanos , Masculino
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