Internal decompressive craniectomy with craniotomy: a novel surgical therapy of giant frontal mucocele complicated by subdural empyema

INTRODUCTION

Giant frontal mucocele (GFM) is an extremely rare cause of frontal lobe syndrome. Subdural empyema (SDE) is an uncommon complication of paranasal sinisutis, for which craniotomy and decompressive craniotomy are the most effective surgical procedures.

CASE REPORT

A 54-year-old man was brought unconscious to the Emergency Room where recurrent generalized seizures occurred. Heroine abuse, HCV related hepatitis, prolonged antibiotic therapy for treatment of purulent rhinorrhea, along with recent personality changes, was reported. High white blood cell count, pansinusitis, GFM, SDE and cerebritis were documented. The patient underwent bifrontal craniotomy in emergency, extensive drilling of the inner aspect of the frontal bone, surgical toilette of the enlarged frontal sinus and its "cranialization". Prevotella intermedia and Fusobacterium nucleatum were isolated and antibiotic therapy was started intravenously and then continued orally for three months. Two years later the patient has recovered, though minor signs of frontal lobe syndrome persist.

DISCUSSION

To the Authors knowledge this is the first case of GFM with SDE reported in the literature. Although decompressive craniectomy is advocated in extreme conditions, as in this case, "internal decompressive craniectomy", obtained with craniotomy and cranialization of the frontal sinuses, is strongly advocated in cases of SDE associated with megasinuses.

Endoscope-assisted microsurgical transoral approach to the anterior craniovertebral junction compressive pathologies

At the present time, an update to the classical microsurgical transoral decompression is strongly provided by the most recent literature dealing with the introduction of the endoscopy in spine surgery. In this paper, we present our experience on the endoscope-assisted microsurgical transoral approach to anterior craniovertebral junction (CVJ) compressive pathology. We analysed seven patients (3 paediatrics and 4 adults ranging from 6 to 78 years) operated on for CVJ decompressive procedures using an open access, microsurgical technique, neuronavigation and endoscopy. All techniques mentioned were simultaneously employed. Among the endoscopic routes described in the literature, we have preferred the transoral using 30° endoscopes. In all the cases endoscopy allowed a radical decompression compared to the microsurgical technique alone, as confirmed intraoperatively with contrast medium fluoroscopy. In conclusion, endoscopy represents a useful complement to the standard microsurgical approach to the anterior CVJ; it provides information for a better decompression with no need for soft palate splitting, hard palate resection, or extended maxillotomy. Moreover, intraoperative fluoroscopy helps to recognize residual compression. Virtually, in normal anatomic conditions, no surgical limitations exist for endoscopically assisted transoral approach, compared with the pure endonasal and transcervical endoscopic approaches. In our opinion, the endoscope deserves a role as "support" to the standard transoral microsurgical approach since 30° angulated endoscopy significantly increases the surgical area exposed at the level of the anterior CVJ.

The differentiation of the newborn nerve cells in oculomotor nuclear after oculomotor nerve injury

Oculomotor nerve injury is a common complication of cranial trauma and craniotomy. For a long time, it has been generally considered that the oculomotor nerve is unable to regenerate and recover functionally after injury. With the development of neuroradiology, microsurgery and neurohistology, it has been reported that the injured oculomotor nerve could be repaired by operation. However, the mechanisms of neural regeneration of the injured oculomotor nerve remain obscure. Therefore, by investigating the differentiation of the newborn nerve cells in oculomotor nuclear after oculomotor nerve injury, the mechanisms of the neural regeneration of the injured oculomotor nerve was studied in the present paper. After animal model establishment, we found that the function of the injured oculomotor nerve could recover at some degree without treatment, at fourth week after the nerve injury. This result confirms that the injured oculomotor nerve per se has the potential to regenerate and repair. At the present study, by BredU stain, BrdU labeling cells were observed in oculomotor nuclear at the fourth week post-operatively. It indicated that the oculomotor nuclear per se has the ability of generating the cells, which will regenerate and differentiate after the nerve injury, without stimulation by exogenous agents. Immunofluorescence double staining was used in this study to show the differentiation of the newborn cells in oculomotor nuclear after oculomotor nerve injury. It is found that they could differentiate into neural progenitor cells, neuronal cells and neuroglial cells. It is suggested that the different differentiation of cells may play a role in the nerve regeneration procedure.

Synovial sarcoma of the parotid gland: a case report and review of the literature

Parotid gland tumours are very heterogeneous, being benign in 80% of cases, and generally arising from epithelial cells. Nevertheless, a small group of non-epithelial tumours representing just 5% of all salivary gland neoplasms has also been reported, the most common of these being haemangioma, especially in children. However, lymphomas, neuromas, neurofibromas, lipomas and sarcomas can also be found. Synovial cell sarcoma is a high grade histological variety of sarcoma and is generally located near large joints and bursae of the lower extremities, such as knee, tendon sheaths and bursal structures. It is rarely found in the head and neck region due to its lack of synovioblastic tissue. Herewith, the case of a young female, affected by a synovial sarcoma of the left parotid gland, is presented and a review is made of the literature on this rare specific localization focusing on management and outcome.

Clinical analysis of hyponatremia in acute craniocerebral injury

OBJECTIVE

To explore pathological mechanisms of central hyponatremia and its treatment.

METHODS

Synchronous assay was made for changes of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), endogenous digitalis-like substance (EDLS), antidiuretic hormone (ADH) in blood, and Na(+) concentrations in blood and urine, and plasma- and urine-osmolality in 68 patients with acute craniocerebral injury (ACI).

RESULTS

Of the 68 patients with ACI, 27 were found to have hyponatremia, and such illness was mostly concentrated on severe cases.

CONCLUSIONS

The central hyponatremia in patients with ACI may be related to the increase in the secretion of EDLS and ADH as the result of damaged functions of the hypothalamic-hypophysial system, and it seems that the decrease in blood ANP and BNP has no direct effect on Na(+) concentrations in blood. Inappropriate secretion of antidiuretic hormone syndrome and cerebral salt-wasting syndrome are the two main reasons for hyponatremia in patients with craniocerebral injury. The pathological mechanism, diagnostic standards, as well as treatment methods for the two, however, are not just the same. Intravenous injection of extrinsic thyrotropin-releasing hormone might inhibit dilutional hyponatremia arising from the increase in ADH secretion by patients with ACI.

Morphological and functional MR imaging of Lhermitte-Duclos disease with pathology correlate

Lhermitte-Duclos disease (LDD) is a rare benign lesion of uncertain pathogenesis characterised by distortion of the normal cerebellar laminar cytoarchitecture. We report a case of LDD thoroughly characterized by advanced magnetic resonance imaging techniques, with diffusion-weighted, perfusion-weighted and post-gadolinium sequences. Imaging showed restricted diffusion consistent with high cellularity, high degree of vascularity and preserved blood-brain barrier permeability, correlating with pathology.

Natriuretic Peptides, Antidiuretic Hormone and Hyponatraemia after Acute Craniocerebral Injury

We investigated the physiological mechanisms involved in central hyponatraemia in patients with acute craniocerebral injury (ACI). We measured blood concentrations of natriuretic peptides, antidiuretic hormone (ADH), and endogenous digitalis-like substance (EDLS), blood and urine sodium concentrations, and the plasma and urine osmolality in 68 patients with ACI and 24 healthy control subjects. A total of 27 ACI patients were hyponatraemic and the majority of these had grievous or severely grievous craniocerebral injuries. Blood concentrations of EDLS and ADH in hyponatraemic ACI patients were significantly higher compared with normonatraemic ACI patients and control subjects. Blood EDLS and sodium concentrations were negatively correlated with each other, whereas EDLS was positively correlated with urine sodium concentration and with urine osmotic pressure. Hyponatraemic ACI patients require different treatment based on the cause of their central hyponatraemia, so it is important to undertake a comprehensive analysis of each patient's physiological status.

Neuromodulation of cerebral blood flow by spinal cord electrical stimulation: the role of the Italian school and state of art

Hosobuchi first studied the effect of spinal cord stimulation (SCS) on cerebral blood flow (CBF) in human beings along with the demonstration that SCS can improve peripheral blood flow. Following these clinical and experimental observations Hosobuchi first used cervical SCS for the treatment of cerebral ischemia in man. Further experimental reports suggested so far that SCS 1) drastically prevents cerebral infarction progression along with a reduction in infarct volume in cats; 2) improves clinical symptoms of patients in persistent vegetative states; 3) suppress headache attacks in migraneous patients; 4) significantly reduces ischemic brain oedema in rats; 5) increase locoregional blood flow in high grade brain tumors. The authors found that SCS can produce either an increase of CBF or a reduction or no effect. In patients studied with both SPECT technique and transcranial Doppler (TCD) the sign of the induced variations, when present in both, as the same. Cervical stimulation produces more frequently an increase in CBF (61% of cervical stimulations). The authors' experimental studies confirm that SCS 1) interacts with CO2 with the mechanism of regulation of CBF in a competitive way and produce a reversible functional sympathectomy; 2) produces similar flowmetric changes in the brain as well as in the eyes; 3) can improve both clinical and haemodynamic ischemic stroke in humans; 4) prevents hemodynamic deterioration in the experimental combined ischemic and traumatic brain injury; 5) prevents experimental early vasospasm.

Haemodynamic patterns in children with posttraumatic diffuse brain swelling. A preliminary study in 6 cases with neuroradiological features consistent with diffuse axonal injury

BACKGROUND

In the present report we describe the cerebral haemodynamics and the neuroradiological findings observed in six consecutive children, three males and three females aged 4-15.6 yrs (mean age 8.95) displaying a neuroradiological pattern consistent with diffuse axonal injury (DAI) along with slit ventricles.

METHODS

All the patients were admitted to the Paediatric Intensive Care Unit with GCS scores less than 8 after a severe brain injury. Serial head computed to mography (CT) and magnetic resonance (MR) scans demonstrated a radiological pattern of DAI. Transcranial Doppler Sonography (TCD) of the middle cerebral arteries was performed through the temporal bone window in all the patients. All patients but one underwent a continuous monitoring of intracranial pressure (ICP) and cerebral extraction of O(2) (CEO(2)). Treatment with barbiturates and hyperventilation was necessary in all the cases. In one patient, a bilateral decompressive cran iectomy was performed in order to decrease severe in tracranial hypertension.

RESULTS

Hyperflow along with intracranial hyper tension, variably responsive to barbiturate medication, was observed in all the patients by means of TCD and CEO(2).

CONCLUSIONS

Intracranial hypertension can be elevated in pediatric posttraumatic hyperflow syndromes associated with DAI. The observation of the time course of the parameters studied allowed us to modify the pharmacological treatment and/or perform surgical decompression (external cerebrospinal fluid (CSF) drainage in five cases; decompressive craniectomy in one case). Compartmental hyperflow TCD pattern was evident in only one patient. Although the limited number of pa tients in our series does not allow definite conclusions, we strongly believe that TCD, with ICP and CEO(2) monitoring, are useful tools in planning surgical strategy in children with neuroradiological signs of DAI.

A new animal model for monitoring the early cerebral vasospasm after subarachnoid haemorrhage

AIM

Spasm of cerebral arteries is a complication associated with subarachnoid haemorrhage. The aim of the present work is to find an experimental model of reliable, simple and in vivo monitoring of ''early'' basilar artery spasm after subarachnoid haemorrhage (SAH). Early spasm occurs within minutes of the SAH, its duration is approximately 1 hour. The need of different morphological and haemodynamic methods to evaluate experimental early spasm is reported.

METHODS

To overcome intracranial surgical manipulations and biological of contrast and fixation media we designed a model that allows in vivo functional monitoring of basilar blood flow far away from the spasm without direct surgical and chemical interferences. Seventeen adult Burgundy rabbits were studied.

RESULTS

Under homeostatic monitoring ''on-line'' carotid blood flow (carotid BF) .changes produced by SAH in cisterna magna of 12 (plus 5 sham treated) animals were studied from the common carotid artery after external carotid artery occlusion before, during SAH up to the end of the experiments. All the animals underwent digital subtraction cerebral panangiography (CPA) after SAH obtaining a significant increase of carotid BF only when basilar vasospasm was shown by CPA.

CONCLUSIONS

Carotid BF increase during basilar vasospasm was defined ''functional. monitoring'' of early spasm.

Spinal cord stimulation and cerebral haemodynamics

After the demonstration that spinal cord stimulation (SCS) can improve peripheral blood flow it was Hosobuchi ('86) who first studied the effect of SCS on cerebral blood flow (CBF) in human beings. Our group found that SCS can produce either an increase of CBF or a reduction or no effect. In patients studied with both SPECT technique and TCD, the sign of the induced variations, when present in both, was the same. Cervical stimulation produces more frequently an increase in CBF (61% of cervical stimulations). Our experimental studies confirm that SCS and CO2 interact with the mechanism of regulation of CBF in a competitive way and produce a reversible functional sympathectomy. Further experimental reports suggest that SCS 1) drastically prevents cerebral infarction progression in cats; 2) improves clinical symptoms of patients in persistent vegetative states; 3) suppress headache attacks in migraneous patients; 4) significantly reduces ischemic brain oedema in rats. Following these clinical and experimental observations, Hosobuchi first used cervical SCS for the treatment of cerebral ischemia in man ('91). More recently we confirmed the therapeutic effect of SCS on ischemic stroke in humans, experimental brain injury and cerebral vasospasm in rabbits.

Effect of spinal cord stimulation on spontaneous and stress-induced angina and 'ischemia-like' ST-segment depression in patients with cardiac syndrome X

AIMS

A significant number of patients with cardiac syndrome X (CSX) present frequent episodes of severe chest pain, refractory to maximal multi-drug therapy. A few, small, uncontrolled data suggested that spinal cord stimulation (SCS) may have favourable clinical benefits in these patients.

METHODS AND RESULTS

We studied 10 CSX patients who were being treated by SCS for refractory angina pectoris for 17+/-16 months (median 8). Patients were randomized to either continue or withdraw SCS for a period of 3 weeks and were then crossed over to the other condition for a further 3-week period. During each 3-week period patients kept a detailed diary of angina episodes occurring in the last 2 weeks of each phase. Furthermore, at the end of each 3-week period, angina status was also assessed by Seattle Angina Questionnaire (SAQ), a 0-100 visual analogue scale (VAS), and patients underwent 24-h Holter monitoring (HM) and echocardiographic dobutamine stress test (DST). Compared with the withdrawal phase, SCS reduced the number (P=0.01), duration (P=0.022), and severity (P=0.011) of angina episodes, and nitrate consumption (P=0.042). SAQ scores (P< or =0.013 for all) and VAS (P<0.001) were also improved, the number of episodes of ST-segment depression on HM was decreased (P=0.014), and time to angina (P=0.045) and to 1 mm ST-segment depression (P=0.04) during DST were both prolonged by SCS.

CONCLUSIONS

Our data point out that SCS may be an effective form of treatment in patients with CSX suffering from frequent angina episodes significantly impairing quality of life (QOL) and refractory to maximally tolerated drug therapy.

Subacute clinical onset of postraumatic myelopathy

BACKGROUND

Subacute neurological deterioration unrelated to mechanical instability is a rare event.

CASES REPORT

The authors describe two patients with subacute neurological deterioration unrelated to mechanical instability, which occurred 24 hours after spinal cord injury.The phenomenon could not be prevented by steroid therapy carried out either before or after the onset of clinical signs. An early surgical decompressive procedure performed in one of the two patients, failed to reverse the clinical symptomatology.

FINDINGS

In the first case, temporal evolution of the neurological deterioration suggested a venous thrombosis with secondary congestive ischemia, whereas ischemia involving the anterior spinal artery seems to account for the deterioration observed in the second patient.

INTERPRETATION

Spinal cord haemodynamics plays the main role in mediating the onset of descending subacute posttraumatic myelopathy. The cure and the prevention of the secondary vascular injury still remains unknown.

Craniocervical junction instability: instrumentation and fusion with titanium rods and sublaminar wires. Effectiveness and failures in personal experience

BACKGROUND

The aim of the study was to evaluate the effectiveness, pitfalls and failures of instrumentation and fusion with titanium wires and rods in 12 h patients with craniovertebral junction instability.

METHODS

Among nine adult patients (mean age 48.11 years) with craniovertebral junction instability, four had basilar impression, three metastatic disease, one rheumatoid arthritis and one Down's syndrome. Three children (mean age 7.33 years) with genetic (Down's syndrome, 2 cases) and metabolic (mucopolisaccarydoses type IV, i.e. Morquio Syndrome, 1 case) disease were studied as well. Each patient underwent preoperative radiological evaluation by means of X-Ray, CT scan and MRI of the craniocervical region. Occipitocervical instrumentation with a titanium U-shaped wired rod was performed in each patient. Autologous bone fusion was performed in all but the two cancer patients, in whom polymethylmetacrylate was used. Postoperatively, all the patients used an external orthosis for 3-6 months. Post-operative X-Ray, CT and MRI were performed on each patient. The Frankel clinical scale was used to asses the outcome at follow-up which ranged from 1 to 10 years. At maximum follow up, there was either clinical improvement or stabilization recorded in all but one patient. This patient with basilar impression transiently worsened from grade D to C and a spinal cord lesion was already evident before the operation on MRI examination.

INTERPRETATION

The effectiveness of surgical management of craniovertebral junction instability by instrumentation and fusion was demonstratedly in our experience. Nevertheless, the choice of the surgical technique should be made with caution when a spinal cord lesion is revealed by preoperative neuroimaging studies.

Protective effect of spinal cord stimulation on experimental early cerebral vasospasm. Conclusive results

In this study we investigate the effects of cervical spinal cord stimulation (cSCS) on experimental 'early spasm' in rabbits as described in personal previous experience (Acta Neurochir 2001;143:177-185). Twenty-four adult red Burgundy rabbits wearing a cervical epidural electrode underwent cerebral blood flow (CBF) and functional monitoring of early basilar spasm before and during cSCS. CBF changes, as a consequence of cSCS, occurred in 20 control animals. No CBF changes, consistent with no basilar artery vasospasm, occurred after subarachnoid haemorrhage (SAH) up to the end of the experiments in all the stimulated animals. The role of reversible functional sympathectomy in mediating the effect of spinal cord stimulation on early spasm is discussed. cSCS is able to prevent 'early spasm' due to SAH in all the animals studied, independently from the occurrence and the sign of stimulation induced CBF variations.

Spinal cord stimulation and cerebral blood flow in stroke: personal experience

Spinal cord stimulation (SCS) can increase cerebral blood flow (CBF) and improve stroke patients. In order to better understand the haemodynamic changes underlining the clinical improvement, we have studied with transcranial Doppler (TCD), SPECT and NIRS 18 patients harbouring a stroke. SPECT Group: An increase of regional CBF during SCS was measured far from the stroke areas in 9 patients, further decrease in CBF was found in 2, no changes in 1. TCD Group: An increase of CBF velocities during SCS was found in 4 patients, no changes in 6, a decrease in 1. NIRS Group: Data consistent with and increase in CBF were obtained during SCS in the only patient undergone such a study. In 6 patients studied with different techniques, data obtained fitted only in 2 patients. In 3 patients no changes in TCD faced with changes in SPECT. In one case an improvement in TCD was evident in the left while an improvement of SPECT was shown in the right site. SCS is a valid therapeutic tool in stroke patient even if, as matter of fact, parallelism between clinical and haemodynamic changes during SCS is not demonstrated in our patients, rising the question on the role of ischemic penumbra in mediating clinical improvement.

Spinal cord stimulation prevents the effects of combined experimental ischemic and traumatic brain injury. An MR study

Spinal cord stimulation (SCS) interferes with cerebral blood flow (CBF). In this paper we try to evaluate the possible preventing effect of SCS in an animal model of combined ischemic and traumatic injury. We studied 20 New Zealand rabbits undergoing ligature of both carotid arteries and a right hemispheric craniectomy and about 3 h mechanical injury (200 mg) over the dura. In 10 animals (control group) SCS was not delivered; in 10 (SCS group) cervical SCS was started 20 min after arterial ligation and before the craniectomy and the mechanical injury. MR examination was performed in all the animals at the end of the experiments. Compared to the control group none but one of the SCS showed lesional pattern far from the craniectomy suggesting a 'preventing' effect of SCS on the secondary damage associated with our model combined ischemic and traumatic brain injury.