RESUMO
BACKGROUND: Low-pressure hydrocephalus (LPH) is a relatively rare condition, and its presentation is similar to the classically seen high-pressure hydrocephalus, with headaches, cranial nerve dysfunction, ataxia, and disturbances of consciousness. Cerebral cerebrospinal fluid loss in the presence of altered brain viscoelastic properties has previously been suggested as the pathophysiologic process leading to ventriculomegaly, despite low or negative intracranial pressures and patent shunts. More recently, cerebral venous overdrainage has been proposed as a possible explanation in the pathogenesis of LPH, although its connection to lumbar punctures in patients with shunts has not been contemplated yet. The effectiveness of epidural blood patch in the management of post-lumbar puncture LPH has been shown in children but has not been reported in adults. CASE DESCRIPTION: Herein we detail 2 episodes of shunt malfunction in a 30-year-old female patient with a history of hydrocephalus related to a posterior fossa tumor diagnosed during childhood. In both instances, imaging studies demonstrated ventricular dilation along with perimedullary cistern enlargement and brainstem distortion, which occurred following a lumbar puncture despite a patent shunt. A lumbar blood patch was effective in both episodes, enabling resolution of the ventriculomegaly and a good outcome. CONCLUSIONS: A blood patch can be efficient in adults with post-lumbar puncture LPH. Some symptoms may be explained by brainstem compression caused by enlarged cerebrospinal fluid spaces at the skull base. The role of cerebral venous overdrainage in the setting of post-lumbar puncture LPH is further supported.
Assuntos
Placa de Sangue Epidural/métodos , Vazamento de Líquido Cefalorraquidiano/terapia , Cefaleia/terapia , Hidrocefalia/terapia , Pressão Intracraniana , Punção Espinal/efeitos adversos , Derivação Ventriculoperitoneal , Adulto , Neoplasias Cerebelares/terapia , Vazamento de Líquido Cefalorraquidiano/etiologia , Falha de Equipamento , Feminino , Cefaleia/etiologia , Humanos , Meduloblastoma/terapiaRESUMO
OBJECT: The aim of this study was to review the historical developments and current status of superficial temporal artery (STA) to middle cerebral artery (MCA) bypass. METHOD: A literature review was performed to review the origins and current uses of the STA bypass procedure in neurosurgery. RESULTS: The idea of providing additional blood supply to the brain to prevent stroke and maintain neurological function has been present in the mind of neurosurgeons for many decades. In 1967 the first STA-MCA bypass was done by M. G. Yasargil, and an enormous step was made into the field of microneurosurgery and cerebral revascularization. During the decades that followed, this technique was used as an adjuvant or a definitive surgical treatment for occlusive disease of the extracranial and intracranial cerebral vessels, skull base tumors, aneurysms, carotid-cavernous fistulas, cerebral vasospasm, acute cerebral ischemia, and moyamoya disease. With the results of the first randomized extracranial-intracranial (EC-IC) bypass trial and the development of endovascular techniques such as angioplasty for intracranial atherosclerotic disease and cerebral vasospasm, the indications for STA-MCA bypass became limited. Neurosurgeons continued to perform EC-IC bypasses as an adjuvant to clipping of aneurysms and in the treatment of skull base tumors and moyamoya disease; the procedure is less commonly used for atherosclerotic carotid artery occlusion (CAO) with definite evidence of hemodynamic insufficiency. The evidence that patients with symptomatic CAO and "misery perfusion" have an increased stroke risk has prompted a second trial for evaluating EC-IC bypass for stroke prevention. The Carotid Occlusion Surgery Study is a new trial designed to determine whether STA-MCA bypass can reduce the incidence of stroke in these patients. New trials will also reveal the role of the STA-MCA bypass in the prevention of hemorrhages in moyamoya disease. CONCLUSIONS: The role of STA-MCA bypass in the management of cerebrovascular disease continues to be refined and evaluated using advanced imaging techniques and by performing randomized trials for specific purposes, including symptomatic CAO.
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Revascularização Cerebral/história , Transtornos Cerebrovasculares/história , Revascularização Cerebral/métodos , Revascularização Cerebral/tendências , Transtornos Cerebrovasculares/fisiopatologia , Transtornos Cerebrovasculares/cirurgia , Alemanha , História do Século XX , Humanos , Estados UnidosRESUMO
Various mixed associations between arteriovenous malformations, cavernous malformations, developmental venous anomalies, and capillary telangiectasias have been described, and a common pathophysiologic event has been suggested to be present, although it is yet to be elucidated. We depict herein the imaging features of a patient who presented with a spontaneous cerebellar hemorrhage, in whom radiologic studies demonstrated a pontine telangiectasia, a brainstem/cerebellar developmental venous anomaly, and a cerebellar proliferative angiopathy. This unique, not previously reported combination of lesions shows that the spectrum of mixed vascular malformations continues to expand. A pathophysiologic mechanism related to the angiogenesis seen in these malformations is also hypothesized.
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Angioma Venoso do Sistema Nervoso Central/diagnóstico por imagem , Cerebelo/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Ponte/diagnóstico por imagem , Telangiectasia/diagnóstico por imagem , Angioma Venoso do Sistema Nervoso Central/complicações , Angioma Venoso do Sistema Nervoso Central/cirurgia , Cerebelo/irrigação sanguínea , Cerebelo/cirurgia , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/cirurgia , Pessoa de Meia-Idade , Ponte/irrigação sanguínea , Ponte/cirurgia , Telangiectasia/complicações , Telangiectasia/cirurgiaRESUMO
Cortical vein thrombosis is an uncommon cause of stroke and generally occurs in the supratentorial compartment. Spontaneous venous thrombosis with infarction in the posterior fossa usually occurs in association with either dural sinus thrombosis and/or thrombosis of the petrosal vein, usually with venous infarction of the cerebellar hemisphere. Our goal is to present the case of a patient with thrombosis of cerebellar cortical veins, without sinus involvement, which mimicked a vermian cerebellar tumor.
Assuntos
Córtex Cerebelar/patologia , Trombose Venosa/diagnóstico por imagem , Córtex Cerebelar/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Trombose Venosa/patologia , Trombose Venosa/cirurgiaRESUMO
BACKGROUND: Management of encephaloceles is challenging when massive brain herniation is present. In such instances, an expansile cranioplasty may be attempted so as to preserve some herniated brain tissue. Complications such as wound dehiscence, cerebrospinal fluid leak, and scalp necrosis are postoperative concerns. The treatment of scalp necrosis with dural and brain exposure is certainly a challenge due to the complexity of flap techniques in such a young age. Herein we describe the use of a novel technique for the management of a scalp necrosis and dehiscence in an infant. CASE DESCRIPTION: A patient with a giant parietal encephalocele and massive brain herniation underwent an expansile cranioplasty. A large scalp necrosis ensued as a complication and later progressed to a suture dehiscence despite a new surgical intervention, with resultant brain exposure. A scalp reconstruction was subsequently performed using an artificial dermal substitute, laid directly onto the brain, followed by a split-thickness skin graft. We observed a rapid engraftment, without any further complications, with an acceptable cosmetic result in the long-term follow-up. CONCLUSION: A simple technique, such as the use of an artificial dermal matrix with simultaneous split-thickness skin graft, may be an effective treatment for the repair of scalp defects, even when coverage of exposed brain tissue is necessary, when no other techniques are found to be suitable.
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Colágeno/uso terapêutico , Elastina/uso terapêutico , Necrose/cirurgia , Procedimentos de Cirurgia Plástica/métodos , Complicações Pós-Operatórias/cirurgia , Couro Cabeludo/patologia , Encefalocele/diagnóstico por imagem , Encefalocele/cirurgia , Feminino , Humanos , Lactente , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética , Necrose/diagnóstico por imagem , Necrose/etiologia , Necrose/terapia , Diagnóstico Pré-NatalRESUMO
BACKGROUND: Iliac screw placement is challenging due to the particular anatomy of the ilium. Most series have reported the use of relatively short (≤90 mm in length) screws despite a long iliac buttress, which has an average length of 129 mm in females and 141 mm in males. This study describes a series of 14 patients who underwent placement of long iliac screws (≥100 mm in length) as part of a spinopelvic fusion utilizing fluoroscopy alone. METHODS: All patients who received at least one long iliac screw were included in this study. Placement accuracy, the average distance from the screw tip to the anterior inferior iliac spine (AIIS), neurovascular injuries, acetabulum and/or sciatic notch violations, and screw prominence were all measured. RESULTS: Fourteen patients received 38 iliac screws, with 31 screws being ≥100 mm in length. The accuracy rate was 87.1% (27/31) for the long iliac screws. The average shortest distance from the iliac screw tip to the AIIS was 15.5 mm for the right-sided and 17.1 mm for the left-sided ilia. There were no neurovascular injuries, acetabulum, or sciatic notch violations, and no screws loosened or fractured. Of interest, only one patient required off-set connectors to link the rods to the iliac screws. CONCLUSIONS: Placement of long iliac screws under intraoperative fluoroscopy only was shown to be feasible, with a high accuracy rate and few complications, in this series of patients.
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BACKGROUND: Trastuzumab emtansine, an antibody-drug conjugate commonly abbreviated as T-DM1, is accepted as effective therapy for trastuzumab-resistant metastatic HER2-positive breast cancer. T-DM1 significantly increases progression-free and overall survival when compared with lapatinib plus capecitabine in patients with HER2-positive breast cancer previously treated with trastuzumab and a taxane. Among the common side effects related to T-DM1, thrombocytopenia and mucosal hemorrhage are seen, although they are infrequently judged to be clinically significant. Intracranial hemorrhages are extremely rare, and only 3 cases of hematomas have been reported in association with T-DM1 and remote radiotherapy, 2 of them with progressive enlargement. OBJECTIVE: Herein we describe a patient who presented with a cerebellar hematoma that progressively enlarged over 8 months during treatment with T-DM1 and only a few months after whole-brain radiation therapy plus a stereotactic radiosurgery boost for a HER2-positive breast cancer cerebellar metastasis. The pathology of the hematoma was similar to that in previous cases and suggested a unique pathophysiology related to an interaction between T-DMI and radiation therapy. CONCLUSIONS: A progressively enlarging intraparenchymal hematoma can be seen just a few months after delivery of radiation therapy for a metastatic brain lesion in HER2-positive breast cancer patients who are receiving T-DM1. In such patients, even a small focus of hemorrhage on magnetic resonance images should prompt close follow-up with serial imaging.
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Doenças Cerebelares/etiologia , Hematoma/etiologia , Maitansina/análogos & derivados , Trastuzumab/efeitos adversos , Ado-Trastuzumab Emtansina , Neoplasias Encefálicas/tratamento farmacológico , Neoplasias Encefálicas/radioterapia , Neoplasias Encefálicas/secundário , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/genética , Doenças Cerebelares/diagnóstico por imagem , Angiografia Cerebral , Terapia Combinada/efeitos adversos , Resistencia a Medicamentos Antineoplásicos/genética , Feminino , Hematoma/diagnóstico por imagem , Humanos , Angiografia por Ressonância Magnética , Maitansina/efeitos adversos , Maitansina/uso terapêutico , Pessoa de Meia-Idade , Radiocirurgia , Radioterapia/efeitos adversos , Receptor ErbB-2/genética , Trastuzumab/uso terapêuticoRESUMO
BACKGROUND: U-shaped sacral fractures are highly unstable, can cause significant neurological deficits, lead to progressive deformity and chronic pain if not treated appropriately. OBJECTIVE: To report a case of a U-shaped sacral fracture treated with lumbopelvic fixation and decompression of sacral roots in a 23-year-old man. METHOD: Decompression of the sacral roots combined with internal reduction and lumbopelvic fixation using iliac screws. RESULTS: Restitution of lumbosacropelvic stability and recovery of sphincter function. CONCLUSION: Lumbopelvic fixation is effective in restoring lumbosacralpelvic stability and allows full mobilization in the postoperative period. Good neurological recovery can be expected in the absence of discontinuity of the sacral roots.
Assuntos
Descompressão Cirúrgica , Fixação Interna de Fraturas , Sacro/lesões , Fraturas da Coluna Vertebral/cirurgia , Adulto , Humanos , Masculino , Sacro/cirurgia , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
BACKGROUND: We report the case of a patient with a spondyloptosis who presented with progressive deformity and worsening neurological deficits. The patient had two previous lumbosacral instrumented fusions. CASE DESCRIPTION: A salvage revision surgery was performed, in which long iliac screws along with anterior column support at L5-S1 were used to immobilize the lumbosacral junction. Two years after the procedure a solid fusion is seen along with marked neurological improvement. CONCLUSIONS: Pelvic fixation using long iliac screws is a very useful technique that can be employed when revision surgery for high-grade spondylolisthesis is needed.
RESUMO
BACKGROUND: Chordomas and ecchordosis physaliphora may on rare occasions present with intracranial hemorrhage. Their distinction usually relies on the results of the Ki-67 proliferative index, with a result lower than 1% favoring ecchordosis physaliphora. Intracranial hemorrhagic chordomas have been linked to unfavorable prognosis, due to acute neurologic deterioration and death, or progression after treatment. To the best of our knowledge, this is the first report of a patient with an intracranial hemorrhagic chordoma who had a long progression-free survival. CASE DESCRIPTION: A 67-year-old woman presented with a large hemorrhagic clival tumor that was resected through an endonasal endoscopic approach. Physallipharous cells interspersed in a myxoid matrix, positivity for S-100, cytokeratin, and epithelial membrane antigen were found, along with an extremely low Ki-67 index. Imaging findings of bone erosion, a large size, and enhancement favored the diagnosis of chordoma. The patient received adjuvant stereotactic radiotherapy and has remained disease free after 4 years. CONCLUSIONS: Although hemorrhagic intracranial chordomas have been linked to unfavorable outcomes, our case demonstrates that they may have a low proliferative index, and a long progression-free survival may be seen.
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Cordoma/cirurgia , Hemorragias Intracranianas/cirurgia , Neoplasias da Base do Crânio/cirurgia , Idoso , Cordoma/complicações , Cordoma/diagnóstico por imagem , Fossa Craniana Posterior/diagnóstico por imagem , Fossa Craniana Posterior/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/etiologia , Neoplasias da Base do Crânio/complicações , Neoplasias da Base do Crânio/diagnóstico por imagem , Fatores de TempoRESUMO
Cavernous malformations of the brainstem (CMB) occur less commonly in children than in adults. Their appearance is even rarer in infants, with only five cases reported in the literature. The authors report two additional cases in which giant CMBs were diagnosed in two infants, one when the patient was 1 month old and the other when the patient was 15 months old. A median suboccipital approach in one patient and a pterional-orbitozygomatic approach in the other were used to obtain complete resection of the malformations. Excellent outcomes were achieved in both children. A review of the literature is also presented. It seems that CMBs in infants usually follow a progressive course of growth and associated neurological deterioration. Patients with symptomatic lesions abutting the pial surface should undergo surgical treatment with the goal of cure. An increase may be expected in the number of CMBs diagnosed in children as a result of regular screening of relatives with the familial form of the disease. Nevertheless, due to the small confines of the brainstem, incidental or asymptomatic CMB should still be extraordinary. In the case of such a rare occurrence, conservative treatment should be advocated.
Assuntos
Tronco Encefálico/anormalidades , Tronco Encefálico/irrigação sanguínea , Malformações Vasculares do Sistema Nervoso Central/diagnóstico , Malformações Vasculares do Sistema Nervoso Central/cirurgia , Feminino , Humanos , Lactente , Recém-Nascido , MasculinoRESUMO
OBJECTIVE: To describe our experience with C1 lateral mass screws as part of a construct for C1-2 stabilization and report an alternate method of C1-C2 complex three-point fixation. METHOD: All patients that had at least one screw placed in the lateral mass of C1 as part of a construct for stabilization of the C1-C2 complex entered this study. In selected patients who had a higher chance of nonunion an alternate construct was used: transarticular C1-C2 screws combined with C1 lateral mass screws. RESULTS: Twenty-one C1 lateral mass screws were placed in 11 patients. In three patients the alternate construct was used. All patients had a demonstrable solid and stable fusion on follow-up. CONCLUSION: C1 lateral mass screws are safe and provide immediate stability. The use of C1-C2 transarticular screws combined with C1 lateral mass screws is a feasible and also an excellent alternative for a three-point fixation of the C1-C2 complex.
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Parafusos Ósseos , Vértebras Cervicais/cirurgia , Fixação Interna de Fraturas/métodos , Instabilidade Articular/cirurgia , Fusão Vertebral/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Fixação Interna de Fraturas/instrumentação , Humanos , Pessoa de Meia-Idade , Fusão Vertebral/instrumentação , Resultado do TratamentoRESUMO
OBJECT: Two patients who underwent decompressive craniectomy after head trauma deteriorated secondary to paradoxical herniation, one after lumbar puncture and the other after ventriculoperitoneal shunting. They motivated the authors to investigate further provoked paradoxical herniation. METHODS: The authors reviewed the records of 205 patients who were treated at a single hospital with decompressive craniectomy for head trauma to identify those who had had lumbar puncture performed or a ventriculoperitoneal shunt placed after craniectomy but before cranioplasty. Among the patients who met these criteria, those with provoked paradoxical herniation were identified. The authors also sought to identify similar cases from the literature. Exact binomials were used to calculate 95% CIs. RESULTS: None of 26 patients who underwent a lumbar puncture within 1 month of craniectomy deteriorated, whereas 2 of 10 who underwent a lumbar puncture 1 month afterward did so (20% [95% CI 2.4%-55.6%]). Similarly, after ventriculoperitoneal shunting, 3 of 10 patients deteriorated (30% [95% CI 6.7%-65.2%]). Timing of the procedure and the appearance of the skin flap were important factors in deterioration after lumbar puncture but not after ventriculoperitoneal shunting. A review of the literature identified 15 additional patients with paradoxical herniation provoked by lumbar puncture and 7 by ventriculoperitoneal shunting. CONCLUSIONS: Lumbar puncture and ventriculoperitoneal shunting carry substantial risk when performed in a patient after decompressive craniectomy and before cranioplasty. When the condition that prompts decompression (such as brain swelling associated with stroke or trauma) requires time to resolve, risk is associated with lumbar puncture performed ≥ 1 month after decompressive craniectomy.
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Craniectomia Descompressiva/efeitos adversos , Hérnia/etiologia , Complicações Pós-Operatórias/terapia , Punção Espinal/efeitos adversos , Derivação Ventriculoperitoneal/efeitos adversos , Lesões Encefálicas/cirurgia , Traumatismos Craniocerebrais/cirurgia , Craniectomia Descompressiva/métodos , Hematoma Subdural/complicações , Hematoma Subdural/terapia , Humanos , Estudos Retrospectivos , Fraturas Cranianas/cirurgia , Retalhos Cirúrgicos/patologia , Resultado do TratamentoRESUMO
BACKGROUND CONTEXT: Blunt cerebrovascular injuries (BCVIs) have the potential to cause brain, cerebellar, and/or spinal cord ischemia. Certain subtypes of spine fractures, such as vertebral subluxation, fractures through the foramen transversarium, and C1-C3 fractures have been linked to a higher incidence of BCVI. On the other hand, BCVI in association with craniocervical distraction injuries (CCDs) have been only anecdotally reported. PURPOSE: We hypothesized that because CCD is also caused by a high-energy hyperflexion/hyperextension distraction mechanism, it could also be associated with a high incidence of BCVI. STUDY DESIGN/SETTING: Retrospective chart review. PATIENT SAMPLE: Of 46 consecutive patients with unstable craniocervical dissociations treated operatively at a single Level I trauma center from January 1996 to December 2009, 29 of the 46 had vascular studies that comprised the study sample. OUTCOME MEASURES: Primary outcomes assessed were BCVI subdivided into blunt carotid artery injuries and/or blunt vertebral artery injuries and classified according to the Biffl criteria. Secondary measures included associated strokes and evidence of emboli on transcranial Doppler. METHODS: All consecutive patients diagnosed with unstable CCD injuries that were surgically treated at a single Level I trauma center during the period of 1996 to 2009 were identified. Those who were adequately screened with a catheter angiogram and/or computed tomography angiogram of the neck so as to rule out BCVI were included in this study. Electronic medical records were used to determine mechanism, demographics, clinical findings, and transcranial Doppler reports. Angiography and computed tomography angiograms were analyzed to assess for BCVI. If a BCVI was identified, these were classified using the Biffl criteria. RESULTS: Among the 29 screened patients, 30 BCVIs were identified in 15 patients. According to the Biffl criteria, there were 13 Grade I, eight Grade II, five Grade III, three Grade IV, and one Grade V injuries. Three major strokes were diagnosed in those 15 patients with BCVI, as opposed to none among the other 14 patients without BCVI. CONCLUSIONS: Blunt cerebrovascular injuries were seen in more than 50% of the patients screened, with major strokes occurring in 20% of the patients. We suggest screening for BCVI in all patients presenting with C0-C1 and/or C1-C2 distraction injuries.
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Articulação Atlantoaxial/lesões , Articulação Atlantoccipital/lesões , Traumatismo Cerebrovascular/epidemiologia , Luxações Articulares/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adolescente , Adulto , Traumatismo Cerebrovascular/complicações , Traumatismo Cerebrovascular/cirurgia , Criança , Feminino , Humanos , Luxações Articulares/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Acidente Vascular Cerebral/etiologia , Ferimentos não Penetrantes/epidemiologia , Adulto JovemRESUMO
The superficial temporal artery to middle cerebral artery bypass is an elegant procedure that was developed and first performed by M. Gazi Yasargil. It has been used by neurosurgeons for more than 30 years in the management of neurovascular disorders such as cerebrovascular ischemic disease, moyamoya disease, and complex intracranial aneurysms. Mastering the technique requires not only precise and fine skills but also devoted training in the microsurgery laboratory. The technique presented in this article evolved from the long and vast experience of the senior author (DWN) in performing superficial temporal artery to middle cerebral artery bypasses for a variety of cerebrovascular conditions.
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Revascularização Cerebral/métodos , Transtornos Cerebrovasculares/cirurgia , Artéria Cerebral Média/cirurgia , Artérias Temporais/cirurgia , Anastomose Cirúrgica/métodos , Humanos , Veia Safena/transplanteRESUMO
OBJECTIVE: The preauricular subtemporal-infratemporal (PSI) approach is commonly used to resect clival tumors and other lesions anterior to the brainstem. One of the surgical steps in this approach is a condylar osteotomy or a condylectomy, which often leads to temporomandibular joint dysfunction. We describe a modification of the PSI approach that preserves the temporomandibular joint without sacrificing the ability to mobilize the petrous internal carotid artery or gain surgical access to the clivus and anterior brainstem. METHODS: Anatomic studies in cadaveric specimens were performed, and the extent of exposure of critical skull base and intradural structures was documented with postdissection fine-cut computed tomographic scans. This modification of the PSI approach was subsequently used in three consecutive patients with a clival chondrosarcoma, and the completeness of tumor resection was documented with postoperative magnetic resonance imaging and computed tomographic scans. RESULTS: This approach allowed complete mobilization of the petrous internal carotid artery and surgical access to the mid-lower clivus, jugular tubercle, hypoglossal canal, occipital condyle, anterior brainstem, and the origin of the trigeminal through hypoglossal nerves. It also proved to be safe and feasible in the three patients who underwent surgical resection of a clival chondrosarcoma, allowing a complete tumor removal. CONCLUSION: This variation of the PSI approach is practical, has no additional morbidity, and provides complete access to critical cranial base regions and tumor margins. It can certainly be used as an alternative to the standard PSI approach when dealing with clival tumors and other lesions anterior to the brainstem.
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Tronco Encefálico/patologia , Fossa Craniana Posterior/patologia , Craniotomia/métodos , Côndilo Mandibular/cirurgia , Osso Temporal/cirurgia , Articulação Temporomandibular/patologia , Adulto , Artéria Carótida Interna/patologia , Condrossarcoma/cirurgia , Orelha/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias da Base do Crânio/cirurgiaRESUMO
Although cosmetic defects produced by posterior fossa surgery may not seem obvious, a poor cosmetic result can overshadow an otherwise successful operation. It is important to approach the operation with knowledge that each phase of a surgical procedure either directly or indirectly influences the eventual cosmetic result. The careful use of anatomic dissection and repair and attempts to reconstitute bony defects to their native contour as well as avoidance of complications all contribute to excellent cosmetic outcomes.
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Fossa Craniana Posterior/cirurgia , Estética , Procedimentos de Cirurgia Plástica/métodos , Humanos , CicatrizaçãoRESUMO
OBJECT: The stroke rate, management, and outcome after blunt cerebrovascular occlusion (Biffl Grade IV injury) is not well defined, given the rarity of the disease. Both hemodynamic failure and embolic mechanisms have been implicated in the pathophysiology of subsequent stroke after blunt cerebrovascular occlusion. In this study, the authors evaluated their center's experience with Biffl Grade IV injuries, focusing on elucidating the mechanisms of stroke and their optimal management. METHODS: A retrospective review identified all internal carotid artery (ICA) or vertebral artery (VA) Biffl Grade IV injuries over a 7-year period at a single institution. RESULTS: Fifty-nine Biffl Grade IV injuries were diagnosed affecting 11 ICAs, 44 unilateral VAs, and 2 bilateral VAs. The stroke rates were 64%, 9%, and 50%, respectively. Of the 11 Biffl Grade IV ICA injuries, 5 presented with stroke while 2 developed delayed stroke. An ipsilateral posterior communicating artery greater than 1 mm on CT angiography was protective against stroke due to hemodynamic failure (p = 0.015). All patients with Biffl Grade IV injuries affecting the ICA who had at least 8 emboli per hour on transcranial Doppler (TCD) ultrasonography developed an embolic pattern of stroke (p = 0.006). Treatment with aspirin versus dual antiplatelet therapy had a similar effect on stroke rate in the ICA group (p = 0.5) and all patients who suffered stroke either died (n = 3) or required a decompressive hemicraniectomy with subsequent poor outcome (n = 4). All 10 strokes associated with Biffl Grade IV VA injuries were embolic and clinically asymptomatic. In VA Biffl Grade IV injury, neither the presence of emboli nor treatment with antiplatelet agents affected stroke rates. CONCLUSIONS: At the authors' institution, traumatic ICA occlusion is rare but associated with a high stroke rate. Robust collateral circulation may mitigate its severity. Embolic monitoring with TCD ultrasonography and prophylactic antiplatelet therapy should be used in all ICA Biffl Grade IV injuries. Unilateral VA Biffl Grade IV injury is the most common type of traumatic occlusion and is associated with significantly less morbidity. Embolic monitoring using TCD and prophylactic antiplatelet therapy do not appear to be beneficial in patients with traumatic VA occlusion.
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Lesões Encefálicas/complicações , Estenose das Carótidas/etiologia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Insuficiência Vertebrobasilar/etiologia , Ferimentos não Penetrantes/complicações , Estenose das Carótidas/complicações , Craniectomia Descompressiva , Hemodinâmica/fisiologia , Humanos , Imageamento por Ressonância Magnética , Inibidores da Agregação Plaquetária/uso terapêutico , Prevalência , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/terapia , Resultado do Tratamento , Insuficiência Vertebrobasilar/complicaçõesRESUMO
OBJECT: Horizontal fractures of the anterior arch of the atlas not associated with odontoid fractures have been regarded as stable fractures that can be simply treated with a cervical collar. The authors report that C-1 horizontal fractures also occur in association with severe distraction injuries of the craniocervical junction. METHODS: The authors retrospectively reviewed imaging studies obtained in all surviving patients in whom unstable distraction injuries of the craniocervical junction were diagnosed and in whom surgery was performed at their institution between 1995 and 2009. All patients who also had a C-1 horizontal fracture as a component of their spinal injury were included in the study. RESULTS: Of 47 patients with unstable craniocervical distraction injuries, 5 patients had a horizontal fracture through the anterior ring of C-1: 1 patient had a primarily C1-2 distractive injury whereas 4 others had a grossly unstable injury across the occipitoatlantal junction (occipitoatlantal dissociation). CONCLUSIONS: The finding of a C-1 horizontal fracture does not always reflect a benign injury and its presence should heighten the concern of a more severe and unstable injury at the craniocervical junction.
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Atlas Cervical/lesões , Instabilidade Articular/diagnóstico por imagem , Fraturas da Coluna Vertebral/diagnóstico por imagem , Adolescente , Adulto , Atlas Cervical/diagnóstico por imagem , Atlas Cervical/cirurgia , Feminino , Humanos , Instabilidade Articular/cirurgia , Masculino , Radiografia , Estudos Retrospectivos , Fraturas da Coluna Vertebral/cirurgia , Fusão Vertebral , Resultado do TratamentoRESUMO
STUDY DESIGN: Interobserver and intraobserver reliabilityObjective: To measure and compare the interobserver and intraobserver reliability of the cervical spine injury severity score (CSISS), the subaxial injury classification (SLIC) and severity scale, and the Allen-Ferguson system in patients with subaxial cervical spine injuries presenting to the emergency department. METHODS: Five examiners independently reviewed c-spine x-rays (CT/MRI) of 50 consecutive patients with subaxial cervical-spine injuries. They classified each case using CSISS, SLIC, and the Allen-Ferguson system. Examiners also documented if they believed the case required surgical management. At least 6 weeks later, the above steps were repeated for ten randomly chosen cases. RESULTS: The interobserver and intraobserver reliability for the total CSISS and total SLIC score are excellent. There is poor interobserver reliability and excellent intraobserver reliability when a total kappa score is calculated using all 21 groups for the Allen-Ferguson system. With respect to surgical management decisions, the interobserver agreement is moderate and the intraobserver agreement is excellent. CONCLUSIONS: There is no universally accepted classification scheme for subaxial cervical-spine injuries. A useful classification system must have excellent reliability to consistently and accurately describe injury patterns between different observers and allow for comparison across systems or cohorts. Both the CSISS and the SLIC and severity scale are promising classification systems with excellent interobserver and intraobserver reliability. Future studies will need to determine if their quantitative scores correlate with management and clinical outcomes.