Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center-A Retrospective Study.

Objective We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant ( p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

Contemporary management of scalp cirsoid aneurysm: A dual-trained neurosurgeon's perspective.

OBJECTIVE: Scalp cirsoid aneurysms are subcutaneous arteriovenous fistulae fed by branches of the external carotid artery. They present with progressive scalp swelling and cosmetic deformities in addition to neuro-vascular symptoms. We evaluate the treatment and outcome of this rare vascular lesion with surgery and adjunctive endovascular embolisation performed by a dual-trained neurosurgeon. METHODS: A retrospective analysis of 6 cases operated over a 16 year-period was performed which comprised of clinical data, radiology including angiography and pre-operative embolisation, surgical approaches, outcomes and complications. RESULTS: 6 patients with ages ranging between 26 and 51 years were operated in the study period. All the patients underwent surgical excision of the lesion, of which 2 had undergone pre-operative embolisation of the feeders. There was no recurrence in the follow-up period (Mean 4.7 years) following total excision of the lesions. One patient had post-operative wound dehiscence and another had migration of embolic material to lungs. CONCLUSION: Surgery is the predominant treatment method for scalp cirsoid aneurysms. Various adjunctive endovascular procedures can be performed pre-operatively to minimise operative blood loss.Though lower recurrence is seen with surgery for the scalp AV fistula, embolisation performed in select cases can achieve curative results with appropriate techniques.

Surgical Outcome of Encephaloduroarteriomyosynangiosis for Moyamoya Disease.

OBJECTIVE: Indirect bypass surgeries for moyamoya disease have included modifications of procedures involving placement of the superficial temporal artery on the brain pial surface. We evaluate the functional and angiographic outcomes of patients treated with encephaloduroarteriomyosynangiosis (indirect) revascularization and examine the outcome in relation to demographic and radiological factors. MATERIALS AND METHODS: Patients treated surgically for moyamoya disease over a 14-year period were identified. Demographics, clinical presentation, and radiology were analyzed to assign a stage for the disease (Suzuki staging) and the extent of revascularization (Matsushima grade) at the last follow-up. A modified Rankin score was used to assess the clinical status at presentation and the functional outcome at follow-up. RESULTS: There were 46 patients operated on by a single surgeon over a 14-year period. A higher incidence of motor deficits, seizures, and speech deficits was seen in the pediatric population. Age, sex, preoperative Suzuki disease stage, and hemispheric involvement had no bearing on angiographic outcome at last follow-up. Three of 46 patients (6.5%) developed immediate postoperative complications. Among 43 patients on follow-up, 39 had stable disease or showed improvement in clinical symptoms with 90% event-free status at last follow-up. CONCLUSIONS: Indirect revascularization procedures are an effective alternative to direct cerebral revascularizations in the early or advanced stages of moyamoya disease. This is effective in a predominant ischemic presentation as noted in our series.