Lintene granuloma following microvascular decompression mimicking a cerebellopontine angle tumour.

We describe a case of foreign body granuloma caused by lintene (cotton gauze), placed during microvascular decompression of the fifth nerve for trigeminal neuralgia. At presentation, the clinical and radiological findings were suggestive of a tumor. This is only the second case in the literature of a foreign body granuloma occurring owing to the placement of a lintene pledget during microvascular decompression.

Penetrating injury of the tuberculum sellae.

An unusual case of perforation of the tuberculum sellae and right ethmoid bone by a 10-in. serrated bread knife is described. The patient survived with no neurological or endocrine deficit. The importance of preoperative angiography and control of the proximal and distal vasculature is stressed.

Early hemodynamic changes in experimental intracerebral hemorrhage.

A model of experimental intracerebral hemorrhage is described in which carefully controlled volumes of autologous blood were injected at arterial pressure into the caudate nucleus of the rat. A comparison of intracranial pressure changes and local cerebral blood flow (CBF) was made between three groups of rats, each receiving different injection volumes, and sham-operated control rats by monitoring intraventricular pressure and by obtaining quantitative autoradiographic measurements of CBF within 1 minute of the experimental hemorrhage. Cerebral blood flow was reduced both around the hematoma and in the surrounding brain. This change was strongly volume-dependent and was not accompanied by significant alterations in cerebral perfusion pressure. This finding suggests that the degree of ischemia at the time of an intracerebral bleed depends on the size of the lesion, and implicates local squeezing of the microcirculation by the hematoma, rather than a generalized alteration in perfusion pressure, as the cause of ischemia.

Effects of experimental intracerebral hemorrhage on blood flow, capillary permeability, and histochemistry.

Experimental intracerebral hemorrhage has been shown to cause extensive cerebral ischemia. This study was performed to ascertain the time course of these changes and also to examine the type of brain damage that may occur under such circumstances. Halothane anesthesia was induced in rats, and 25 microliter autologous blood was injected into the caudate nucleus; the effects were studied with autoradiographic measurement of local cerebral blood flow and capillary permeability, and also by light microscopy and histochemical techniques. Blood flow returned to normal or to slightly increased levels within the first 3 hours, and ischemic levels of flow were found to persist only to a marginal degree beyond 10 minutes after the lesions were made. Capillary permeability was maximum during the first 30 minutes after the hemorrhage and diminished with time. Structural evidence of ischemic damage was localized to the cortex overlying the hemorrhage, but was not seen in the caudate nucleus. Nevertheless, histochemical investigation did reveal an area of disturbed enzyme function in the striatum. This finding of biochemical disturbance without structural evidence of ischemic damage reveals that there is an area around the hematoma that, although demonstrating disturbed function, does not show structural damage, and the milieu of this partially injured brain may be implicated in the delayed development of the ischemic brain damage that follows intracerebral hemorrhage in man.

A technique for dural repair following retromastoid suboccipital craniectomy.

The authors describe a simple technique used to achieve a water-tight closure of the dura mater during suboccipital craniectomy.

Alcohol and traumatic brain damage.

Many head-injured patients have been drinking alcohol, and it has been suggested that the effect of a raised blood alcohol may be to potentiate brain damage after head injury. To investigate this, a study was carried out on 38 consecutive, recently head-injured patients admitted to the Glasgow Neurosurgical Unit. Conscious level, blood alcohol and serum creatine kinase BB (CKBB) were measured on admission (the latter by radioimmunoassay). Conscious level related strongly to outcome (chi 2 = 11.678, P less than 0.001), and serum CKBB (chi 2 = 8.333, P less than 0.01) but not to blood alcohol level. In patients with severe head injury admitted to a neurosurgical unit, coma is more likely to be due to the injury than to the blood alcohol level, and alcohol does not adversely affect outcome in such patients.

Prognosis in intracerebral haemorrhage.

A retrospective study of 244 cases of ICH of mixed aetiology was made in respect of clinical course, outcome, and CT findings. Those factors found to be of prognostic significance were: Glasgow coma score on admission, clot volume, degree of midline shift, degree of intraventricular blood, and deterioration in the first postictal 48 hours. Those who required surgical evacuation after 48 hours of onset had a low mortality of 3% compared to 34% in those requiring earlier operation and 27% in the series as a whole. Small haematomas still carried an appreciable mortality and did not bias outcome in the various aetiological groups, although hypertension on admission appeared to be a helpful diagnostic pointer.

Experimental intracerebral haematoma: the role of blood constituents in early ischaemia.

In patients with intracerebral haematoma, ischaemic damage and final outcome are often more serious than the size of the lesion would suggest. The aetiology of the ischaemia in relation to space-occupying effects or specific factors present in blood is unclear. In a rat model of an intracerebral space-occupying lesion, the pathophysiological effects of a haematoma were compared with those of an equal volume of inert fluid (mock cerebrospinal fluid [CSF] or silicone oil). Cerebral blood flow was measured at 1 min by 14C iodoantipyrine autoradiography, and ischaemic cell damage was assessed by light microscopy at 4 h. In all animals, cerebral blood flow was reduced immediately adjacent to the lesion. In the group with a haematoma, blood flow was reduced (p less than 0.001) over a greater radius and also in the ipsilateral frontal and parietal cortex. Ischaemic damage was seen in animals lesioned with blood or oil of blood viscosity, but not in animals with CSF lesions. These data suggest that both tissue pressure and vasoactive substances are components of the immediate reduction in blood flow following intracranial haemorrhage. Tissue pressure may be the more important factor in later ischaemic neuronal damage.

Microvascular decompression for trigeminal neuralgia: report of outcome in patients over 65 years of age.

Microvascular decompression (MVD) is now recognized as an effective operation for the cure of trigeminal neuralgia (TN), and is far superior to the other surgical procedures utilized in the treatment of TN. TN is common in the elderly, but there is debate concerning MVD in 'elderly' patients. Some clinicians have a policy of not offering patients over a certain age the choice of MVD, yet the recurrence rate is inversely related to the age of the patient. Previous failed procedures and a long period of pain before MVD, also affect the outcome negatively. This study is a retrospective review of the outcome in elderly patients following MVD. Forty-two patients over the age of 65 years are reviewed after undergoing MVD for TN. The results indicate that there was no serious morbidity or mortality that could be ascribed to old age and the length of stay in the hospital was not influenced by the age of the patient. The results are compared with the outcome in a younger age group and the literature on MVD for TN reviewed.