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Fermo OP. Evaluation and management of orthostatic headache in hypermobility disorders. Front Neurol 2023; 14:1321350. [PMID: 38162438 PMCID: PMC10755912 DOI: 10.3389/fneur.2023.1321350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
Headache is a frequent symptom among patients with hypermobility spectrum disorders. This mini review focuses specifically on a challenging aspect of headache evaluation in all patients, but especially those with hypermobility - the orthostatic headache. While the differential for an orthostatic headache is overall limited, patients with hypermobility disorders have risk factors for all of the most commonly encountered orthostatic headache disorders. The most common conditions to produce orthostatic headaches are discussed - spontaneous intracranial hypotension, cervicogenic headache, and postural orthostatic tachycardia syndrome. Less common etiologies of orthostatic headache pertinent to any patient are presented in table format.
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Affiliation(s)
- Olga P. Fermo
- Department of Neurology, Mayo Clinic Florida, Jacksonville, FL, United States
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Schucht P, Nowacki A, Osmanagic A, Murek M, Z'Graggen WJ, Montalbetti M, Beck J, Stieglitz L, Raabe A. Space-expanding flap in decompressive hemicraniectomy for stroke. J Neurosurg 2023; 138:382-389. [PMID: 35901672 DOI: 10.3171/2022.5.jns22381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 05/11/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Decompressive hemicraniectomy (DCE) is the standard of care for space-occupying malignant infarction of the medial cerebral artery in suitable patients. After DCE, the brain is susceptible to trauma and at risk for the syndrome of the trephined. This study aimed to assess the feasibility of using temporary space-expanding flaps, implanted during DCE, to shield the brain from these risks while permitting the injured brain to expand. METHODS The authors performed a prospective feasibility study to analyze the safety of space-expanding flaps in 10 patients undergoing DCE and evaluated clinical and radiological outcomes. RESULTS The relatives of 1 patient withdrew consent, leaving 9 patients in the final analysis. No patients required removal of the space-expanding flap because of uncontrolled increase of intracranial pressure or infection. One patient required additional external ventricular drainage and 1 received mannitol. The mean (range) midline shift decreased from 6.67 (3-12) mm to 1.26 (0-2.6) mm after DCE with the space-expanding flap. The authors observed no cases of sinking skin flap syndrome, other complications, or deaths. One patient underwent further treatment due to infection of the reimplanted autologous bone flap. Two patients later refused cranioplasty, preferring to keep the space-expanding flap and thus avoid the potential risks of cranioplasty. CONCLUSIONS This feasibility study showed that the concurrent use of space-expanding flaps appeared to be safe in patients who underwent DCE for malignant infarction of the medial cerebral artery. Moreover, space-expanding flaps may permit patients to avoid a second surgery for reimplantation of the autologous bone flap and the risks inherent to this procedure.
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Affiliation(s)
- Philippe Schucht
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Nowacki
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Armin Osmanagic
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Murek
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Werner J Z'Graggen
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matteo Montalbetti
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- 2Department of Neurosurgery, University Hospital Freiburg im Breisgau, Germany; and
| | - Lennart Stieglitz
- 3Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Andreas Raabe
- 1Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Historical vignette portraying the difference between the “sinking skin flap syndrome” and the “syndrome of the trephined” in decompressive craniectomy. World Neurosurg 2022; 162:11-14. [DOI: 10.1016/j.wneu.2022.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/19/2022]
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Corallo F, Lo Buono V, Calabrò RS, De Cola MC. Can Cranioplasty Be Considered a Tool to Improve Cognitive Recovery Following Traumatic Brain Injury? A 5-Years Retrospective Study. J Clin Med 2021; 10:jcm10225437. [PMID: 34830718 PMCID: PMC8624554 DOI: 10.3390/jcm10225437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 11/17/2021] [Accepted: 11/19/2021] [Indexed: 01/19/2023] Open
Abstract
Cranioplasty (CP) is a neurosurgical intervention of skull repairing following a decompressive craniectomy. Unfortunately, the impact of cranioplasty on cognitive and motor function is still controversial. Fifteen TBI subjects aged 26–54 years with CP after decompressive craniectomy were selected in this observational retrospective study. As per routine clinical practice, a neuropsychological evaluation carried out immediately before the cranioplasty (Pre CP) and one month after the cranioplasty (T0) was used to measure changes due to CP surgery. This assessment was performed each year for 5 years after discharge in order to investigate long-term cognitive changes (T1-T5). Before cranioplasty, about 53.3% of subjects presented a mild to severe cognitive impairment and about 40.0% a normal cognition. After CP, we found a significant improvement in all neuropsychological test scores. The more significant differences in cognitive recovery were detected after four years from CP. Notably, we found significant differences between T4 and T0-T1, as well as between T5 and T0-T1-T2 in all battery tests. This retrospective study further suggests the importance of CP in the complex management of patients with TBI showing how these patients might improve their cognitive function over a long period after the surgical procedure.
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Wittner C, Borowski M, Pirl L, Kastner J, Schrempf A, Schäfer U, Trieb K, Senck S. Thickness accuracy of virtually designed patient-specific implants for large neurocranial defects. J Anat 2021; 239:755-770. [PMID: 34086982 PMCID: PMC8450480 DOI: 10.1111/joa.13465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/27/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
The combination of computer‐aided design (CAD) techniques based on computed tomography (CT) data to generate patient‐specific implants is in use for decades. However, persisting disadvantages are complicated design procedures and rigid reconstruction protocols, for example, for tailored implants mimicking the patient‐specific thickness distribution of missing cranial bone. In this study we used two different approaches, CAD‐ versus thin‐plate spline (TPS)‐based implants, to reconstruct extensive unilateral and bilateral cranial defects in three clinical cases. We used CT data of three complete human crania that were virtually damaged according to the missing regions in the clinical cases. In total, we carried out 132 virtual reconstructions and quantified accuracy from the original to the generated implant and deviations in the resulting implant thickness as root‐mean‐square error (RMSE). Reconstructions using TPS showed an RMSE of 0.08–0.18 mm in relation to geometric accuracy. CAD‐based implants showed an RMSE of 0.50–1.25 mm. RMSE in relation to implant thickness was between 0.63 and 0.70 mm (TPS) while values for CAD‐based implants were significantly higher (0.63–1.67 mm). While both approaches provide implants showing a high accuracy, the TPS‐based approach additionally provides implants that accurately reproduce the patient‐specific thickness distribution of the affected cranial region.
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Affiliation(s)
- Claudia Wittner
- Research Group Computed Tomography, University of Applied Sciences Upper Austria, Wels, Austria
| | - Markus Borowski
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig GmbH, Braunschweig, Germany
| | - Lukas Pirl
- Institut für Röntgendiagnostik und Nuklearmedizin, Städtisches Klinikum Braunschweig GmbH, Braunschweig, Germany
| | - Johann Kastner
- Research Group Computed Tomography, University of Applied Sciences Upper Austria, Wels, Austria
| | - Andreas Schrempf
- Research Group for Surgical Simulators Linz, University of Applied Sciences Upper Austria, Linz, Austria
| | - Ute Schäfer
- Forschungseinheit Experimentelle Neurotraumatologie, Medizinische Universität Graz, Graz, Austria
| | - Klemens Trieb
- Research Group Computed Tomography, University of Applied Sciences Upper Austria, Wels, Austria.,Department of Orthopedic and Trauma Surgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Sascha Senck
- Research Group Computed Tomography, University of Applied Sciences Upper Austria, Wels, Austria
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Recurrent Syndrome of the Trephined in the Setting of Multiple Craniectomy and Cranioplasty. J Craniofac Surg 2020; 31:e705-e707. [PMID: 32804808 DOI: 10.1097/scs.0000000000006625] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Decompressive craniectomy is an increasingly implemented intervention for relief of intracranial hypertension refractory to medical therapy. Despite its therapeutic benefit, a myriad of short and long-term complications may arise when the once fixed-volume cranial vault remains decompressed. The authors present a case of recurrent Syndrome of the Trephined in a patient undergoing repeated craniectomy and cranioplasty.A 70-year old male with history significant for smoking and chronic obstructive pulmonary disease presented with frontoparietal subdural hematoma with midline shift following a ground level fall necessitating craniotomy and hematoma evacuation. Three months postoperatively, the patient developed an infection of his craniotomy bone flap necessitating craniectomy without cranioplasty. Six weeks post-craniectomy the patient began demonstrating right sided sensorimotor deficits with word finding difficulties. Alloplastic cranioplasty was performed following resolution of infection, with resolution of neurologic symptoms 6 weeks post cranioplasty. Due to recurrent cranioplasty infections, multiple alloplastic cranioplasties were performed, each with reliable re-demonstration of neurologic symptoms with craniectomy, and subsequent resolution following each cranioplasty. Final cranioplasty was successfully performed using a new alloplastic implant in combination with latissimus muscle flap, with subsequent return of neurologic function.Decompressive craniectomy is a life-saving procedure, but carries many short- and long-term complications, including the Syndrome of the Trephined. Our case is the first published report, to our knowledge, to demonstrate recurrent Syndrome of the Trephined as a complication of craniectomy, with reliable resolution of the syndrome with restoration of the cranial vault.
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Hakmi H, Joseph DK, Sohail A, Tessler L, Baltazar G, Stright A. Sinking skin flap syndrome in the multi-trauma patient: a paradoxical management to TBI post craniectomy. J Surg Case Rep 2020; 2020:rjaa172. [PMID: 32595925 PMCID: PMC7303104 DOI: 10.1093/jscr/rjaa172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 05/12/2020] [Indexed: 11/13/2022] Open
Abstract
Sinking skin flap syndrome is a rare syndrome leading to increased intracranial pressure, known to neurosurgeons, yet uncommon and hardly ever reported in trauma patients. In a hospitalized trauma patient with declining neurological status, rarely do we encounter further deterioration by elevating the patients' head, diuresis and hyperventilation. However, after craniectomy for trauma, a partially boneless cranium may be compressed by the higher atmospheric pressure, that intracranial pressure rises to dangerous levels. For such cases, paradoxical supportive management with intravenous fluid infusion, and reverse Trendelenburg positioning, is used to counteract the higher atmospheric pressure, as a bridge to definitive treatment with cranioplasty. These steps constitute an urgent and easily applied intervention to reduce further neurological deterioration, of which every trauma healthcare provider should be aware.
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Affiliation(s)
- Hazim Hakmi
- Department of Surgery, NYU Langone Health, New York, 10016, USA
| | | | - Amir Sohail
- Department of Surgery, NYU Langone Health, New York, 10016, USA
| | - Lee Tessler
- Department of Neurosurgery, NYU Langone Health, New York, 10016, USA
| | - Gerard Baltazar
- Department of Surgery, NYU Langone Health, New York, 10016, USA
| | - Adam Stright
- Department of Surgery, NYU Langone Health, New York, 10016, USA
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Computer-Aided-Design/Computer-Aided-Manufacturing Titanium Cranioplasty in a Child: Critical Appraisal. J Craniofac Surg 2019; 31:237-240. [PMID: 31714337 DOI: 10.1097/scs.0000000000005948] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Large skull bone defects of the cranial vault can result from various reasons. Reconstruction of these defects is performed for protective and aesthetic reasons but is also required for adequate intracranial homeostasis. Computer-aided-design/computer-aided-manufacturing (CAD/CAM) patient-specific skull implants have become the most valuable alternative to the traditional methods of reconstruction and a growing number of publications is dealing with this topic in adults. Literature related to the application of these implants in pediatric cranioplasty is, however, still scarce.The authors present a case of a 9-year-old boy, where cranioplasty using a CAD/CAM additive manufactured titanium implant led to improvement of symptoms attributed to cerebrospinal fluid circulation problems and intracranial homeostasis disbalance. The authors further reflect on what the role of cranioplasty should be in the therapeutic treatment plan.
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Dillen WL, Pittman TA, Grupke SL. Novel Temporary Treatment for a Severe Case of Syndrome of Trephined. World Neurosurg 2018; 120:200-204. [DOI: 10.1016/j.wneu.2018.08.153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/19/2018] [Accepted: 08/20/2018] [Indexed: 12/21/2022]
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Zheng F, Xu H, von Spreckelsen N, Stavrinou P, Timmer M, Goldbrunner R, Cao F, Ran Q, Li G, Fan R, Zhang Q, Chen W, Yao S, Krischek B. Early or late cranioplasty following decompressive craniotomy for traumatic brain injury: A systematic review and meta-analysis. J Int Med Res 2018; 46:2503-2512. [PMID: 29779445 PMCID: PMC6124291 DOI: 10.1177/0300060518755148] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 12/19/2017] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate the effectiveness of early (<3 months) cranioplasty (CP) and late CP (>3 months) on post-operative complications in patients receiving decompressive craniotomy (DC) for traumatic brain injury (TBI). Methods The Cochrane Library, PubMed and EMBASE databases were systematically searched for studies published prior to May 21, 2017. A meta-analysis examined post-operative overall complication rates, infection rates, subdural fluid collection and operating times according to early and late CP. Results Of the initial 1675 references, five studies, all cohort, involving a total of 413 patients, were selected for the review. There was no difference between early and late CP in post-operative overall complication rate (RR=0.68, 95%CI [0.36, 1.29]) and the post-operative infection rate (RR=0.50, 95%CI [0.20, 1.24]) in patients receiving DC for TBI. However, there was a significant difference in post-operative subdural effusion (RR=0.24, 95%CI [0.07, 0.78]) and mean operative time (mean difference = -33.02 min, 95%CI [-48.19, -17.84]) both in favour of early CP. Conclusions No differences were found between early and late CP in post-operative overall complications and procedural related infections in patients receiving DC for TBI, but early CP reduced the complication of subdural effusion and the mean operating time. These findings need to be confirmed by large, randomised controlled trials.
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Affiliation(s)
- Feng Zheng
- Department of Neurosurgery, First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Hao Xu
- Department of Neurosurgery, The First Affiliated Hospital of University of Science and Technology of China, Hefei, Anhui, China
| | | | - Pantelis Stavrinou
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Marco Timmer
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Roland Goldbrunner
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
| | - Fang Cao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qishan Ran
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Gang Li
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Ruiming Fan
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Qiang Zhang
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Wei Chen
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Shengtao Yao
- Department of Cerebrovascular Disease, The First Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
| | - Boris Krischek
- Department of Neurosurgery, University Hospital of Cologne, Cologne, Germany
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Montenegro MM, Cutsforth-Gregory JK. Orthostatic Headache After Suboccipital Craniectomy Without CSF Leak: Two Case Reports. Headache 2018; 58:1238-1243. [DOI: 10.1111/head.13346] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 05/10/2018] [Accepted: 05/10/2018] [Indexed: 01/03/2023]
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Abstract
Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.
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Reversibility of Murine Motor Deficits Following Hemi-Craniectomy and Cranioplasty. J Craniofac Surg 2017; 27:1875-1878. [PMID: 27438444 DOI: 10.1097/scs.0000000000002897] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Hemi-craniectomy is a common surgical procedure which allows the brain to swell and herniate and is often utilized to treat traumatic brain injury. When left untreated the scalp skin typically sinks on the side of the craniectomy creating a phenotype termed "sinking skin flap syndrome." In addition, these same patients often develop long-term neurocognitive deficits termed "syndrome of the trephined" as a result of their craniectomy which reverse when the cranial skull is replaced. The authors hypothesize that a mouse animal model can be developed demonstrating long-term neurologic deficits attributed to hemi-craniectomy skull defects similar to humans with syndrome of the trephined. METHODS Thirty C57 mice were randomized among 3 groups: Group 1 = control group (sham surgery), Group 2 = hemi-craniectomy only, and Group 3 = hemi-craniectomy with immediate cranioplasty. Motor deficits were studied using a beam walk test. Statistical comparison of differences among the 3 groups was performed. RESULTS Beam walk test results demonstrated the craniectomy group had a statistically higher contralateral footfault slip/step ratio when compared with the control group (P <0.05). Comparison of the control group and the cranioplasty group demonstrated contralateral footfault slip/step ratio that was statistically different for 7 days postoperative but no statistical differences thereafter. Comparison of the craniectomy group and the cranioplasty group demonstrated statistically significant differences for 14 days; however, motor deficits were not statistically different than baseline thereafter. No ipsilateral footfault deficits were detected in this study. CONCLUSION Motor deficits that are attributed to hemi-craniectomy bone defects alone are demonstrated in a mouse animal model. These motor deficits resemble some symptoms associated with human syndrome of the trephined.
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Case Studies of Uncommon and Rare Headache Disorders. Neurol Clin 2016; 34:631-50. [PMID: 27445245 DOI: 10.1016/j.ncl.2016.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The following 6 case studies are presented: a 12-day migraine with recurring aura?; a migraineur with a new constant headache for 1 month; an orthostatic headache; a unilateral headache; migraine with aura and limb pain without headache; and nocturnal headaches. These cases illustrate the fascinating diversity and challenges of primary and secondary headaches that neurologists commonly encounter.
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Vasung L, Hamard M, Soto MCA, Sommaruga S, Sveikata L, Leemann B, Vargas MI. Radiological signs of the syndrome of the trephined. Neuroradiology 2016; 58:557-568. [DOI: 10.1007/s00234-016-1651-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 01/14/2016] [Indexed: 10/22/2022]
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Wrobel Goldberg S, Young W. Headache Rounds: Sudden Onset Chronic Daily Headache. Headache 2016; 56:379-88. [DOI: 10.1111/head.12724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 08/15/2015] [Accepted: 08/18/2015] [Indexed: 01/03/2023]
Affiliation(s)
- Stephanie Wrobel Goldberg
- Department of Neurology; Thomas Jefferson Headache Center; 900 Walnut Street, Unit 200 Philadelphia PA 19107 USA
| | - William Young
- Department of Neurology; Thomas Jefferson Headache Center; 900 Walnut Street, Unit 200 Philadelphia PA 19107 USA
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Paredes I, Castaño AM, Cepeda S, Alén JAF, Salvador E, Millán JM, Lagares A. The Effect of Cranioplasty on Cerebral Hemodynamics as Measured by Perfusion Computed Tomography and Doppler Ultrasonography. J Neurotrauma 2016; 33:1586-97. [PMID: 26541365 DOI: 10.1089/neu.2015.4261] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cranioplasties are performed to protect the brain and correct cosmetic defects, but there is growing evidence that this procedure may result in neurological improvement. We prospectively studied cranioplasties performed at our hospital over a 5-year period. The National Institute of Health Stroke Scale and Barthel index were recorded prior to and within 72 h after the cranioplasty. A perfusion computed tomography (PCT) and transcranial Doppler sonography (TCDS) were performed prior to and 72 h after the surgery. For the PCT, regions irrigated by the anterior cerebral artery, the middle cerebral artery (MCA), the posterior cerebral artery, and the basal ganglia were selected, as well as the mean values for the hemisphere. The sonography was performed in the sitting and the supine position for the MCA and internal carotid. The velocities, pulsatility index, resistance index, and Lindegaard ratio (LR) were obtained, as well as a variation value for the LR (ΔLR = LR sitting - LR supine). Fifty-four patients were included in the study. Of these, 23 (42.6%) patients presented with objective improvement. The mean cerebral blood flow of the defective side (m-CBF-d) increased from 101.86 to 117.17 mL/100 g/min (p = 0.064), and the m-CBF of the healthy side (m-CBF-h) increased from 128.14 to 145.73 mL/100 g/min (p = 0.028). With regard to the TCDS, the ΔLR was greater on the defective side prior the surgery in those patients who showed improvement (1.295 vs. -0.714; p = 0.002). Cranioplasty resulted in clinical improvement in 40% of the patients, with an increase in the post-surgical CBF. The larger variations in the LR when the patient is moved from the sitting to the supine position might predict the clinical improvement.
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Affiliation(s)
- Igor Paredes
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Ana María Castaño
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | - Santiago Cepeda
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
| | | | - Elena Salvador
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Jose María Millán
- 2 Department of Neuroradiology, University Hospital 12 de Octubre , Madrid, Spain
| | - Alfonso Lagares
- 1 Department of Neurosurgery, University Hospital 12 de Octubre , Madrid, Spain
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Sunderland IR, Edwards G, Mainprize J, Antonyshyn O. A technique for intraoperative creation of patient-specific titanium mesh implants. Plast Surg (Oakv) 2015; 23:95-9. [PMID: 26090350 DOI: 10.4172/plastic-surgery.1000909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Prefabricated, patient-specific alloplastic implants for cranioplasty reduce surgical complexity, decrease operative times, minimize exposure and risk of contamination, and have resulted in improved aesthetic results. However, in creating a prefabricated custom implant using a patient's computed tomography data, a stable, unalterable defect must be clearly defined before surgery. In the event that an intraoperative modification of an exiting skull defect is required, or in cases of tumour resection in which the size of the skull defect is unknown preoperatively, these prefabricated implants cannot be used. The ideal method for alloplastic cranioplasty would enable cost-effective creation of a patient-specific implant with the capacity for intraoperative modification. The present article describes a novel technique of cranioplasty that uses a patient's computed tomography data to create a custom forming tool (ie, mold), enabling intraoperative creation of a patient-specific titanium mesh implant. The utility of these implants in creating a custom reconstructive solution in cases in which the size of the skull defect is unknown preoperatively will be demonstrated using two case presentations.
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Affiliation(s)
- Ian Rp Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Glenn Edwards
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - James Mainprize
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - Oleh Antonyshyn
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
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Sunderland IR, Edwards G, Mainprize J, Antonyshyn O. A technique for intraoperative creation of patient-specific titanium mesh implants. Plast Surg (Oakv) 2015. [DOI: 10.1177/229255031502300204] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Prefabricated, patient-specific alloplastic implants for cranioplasty reduce surgical complexity, decrease operative times, minimize exposure and risk of contamination, and have resulted in improved aesthetic results. However, in creating a prefabricated custom implant using a patient's computed tomography data, a stable, unalterable defect must be clearly defined before surgery. In the event that an intraoperative modification of an exiting skull defect is required, or in cases of tumour resection in which the size of the skull defect is unknown preoperatively, these prefabricated implants cannot be used. The ideal method for alloplastic cranioplasty would enable cost-effective creation of a patient-specific implant with the capacity for intraoperative modification. The present article describes a novel technique of cranioplasty that uses a patient's computed tomography data to create a custom forming tool (ie, mold), enabling intraoperative creation of a patient-specific titanium mesh implant. The utility of these implants in creating a custom reconstructive solution in cases in which the size of the skull defect is unknown preoperatively will be demonstrated using two case presentations.
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Affiliation(s)
- Ian Rp Sunderland
- Division of Plastic and Reconstructive Surgery, University of Saskatchewan, Saskatoon, Saskatchewan
| | - Glenn Edwards
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - James Mainprize
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
| | - Oleh Antonyshyn
- Division of Plastic and Reconstructive Surgery, University of Toronto, Toronto, Ontario
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Annan M, De Toffol B, Hommet C, Mondon K. Sinking skin flap syndrome (or Syndrome of the trephined): A review. Br J Neurosurg 2015; 29:314-8. [DOI: 10.3109/02688697.2015.1012047] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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21
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Paredes I, Castaño-León AM, Munarriz PM, Martínez-Perez R, Cepeda S, Sanz R, Alén JF, Lagares A. Cranioplasty after decompressive craniectomy. A prospective series analyzing complications and clinical improvement. Neurocirugia (Astur) 2014; 26:115-25. [PMID: 25497290 DOI: 10.1016/j.neucir.2014.10.001] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/10/2014] [Accepted: 10/23/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cranioplasty is carried out for cosmetic reasons and for protection, but it may also lead to some neurological improvement after the bone flap placement. Complications of cranioplasty are more frequent than expected for a scheduled neurosurgical procedure. We tried to identify factors associated with both complications and improvement after cranioplasty. METHODS We prospectively studied the cranioplasties performed in our hospital from November 2009 to November 2013. Patients whose initial reason for bone removal was tumor infiltration were excluded. Demographic, clinical and radiological data were collected. The NIH Stroke Scale and Barthel Self-Care Index scores were obtained both before and within 72 h after cranioplasty. The outcome measures were the occurrences of complications and clinical improvement. RESULTS Fifty-five cranioplasties were performed. The material used for the cranioplasty was autologous bone in 42 cases, polyetheretherketone (PEEK) in 7 and methacrylate in 6. The average size of the bone defect was 69.5 (19.5-149.5) cm2. The time elapsed between decompressive craniectomy and cranioplasty was 309 (25-1217) days. There were 10 complications (7 severe and 3 mild), an 18.2% complication rate. Statistically significant risk factors of complications were identified as a Barthel≤70 (Odds ratio [OR] 22; 2.5-192; P=0.005), age over 45 years (OR 13.5; 1.5-115; P=0.01) and early surgery (≤85 days; OR 8; 1.69-37.03, P=0.004). After multivariate analysis, Barthel≤70 and age over 45 years remained independent predictors of complications. Twenty-two (40%) of the 55 patients showed objective improvement. Early surgery (<85 days) increased the likelihood of improvement (OR 4.67; 1.05-20.83; P=0.035). Larger bone defects seemed to be related with improvement, but differences in defect size were not statistically significant (75.3 vs 65.6 cm2; P=0.1). CONCLUSIONS The complication rate of cranioplasty is higher than for other elective neurosurgical procedures. Older age, poorer functional situation (worse Barthel index score) and early surgery (≤85 days) are independent risk factors for complications. However, cranioplasty produces clinical benefits beyond protection and esthetic improvement. Earlier surgery and larger bone defects seem to increase the likelihood of clinical improvement.
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Affiliation(s)
- Igor Paredes
- Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain.
| | | | - Pablo M Munarriz
- Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain
| | | | - Santiago Cepeda
- Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain
| | - Rosa Sanz
- Anesthesiology Department, University Hospital Infanta Leonor, Madrid, Spain
| | - José F Alén
- Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain
| | - Alfonso Lagares
- Neurosurgery Department, University Hospital 12 de Octubre, Madrid, Spain
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Honeybul S. Neurological susceptibility to a skull defect. Surg Neurol Int 2014; 5:83. [PMID: 25024883 PMCID: PMC4093740 DOI: 10.4103/2152-7806.133886] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/07/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There continues to be considerable interest in the use of decompressive craniectomy in the management of neurological emergencies. The procedure is technically straightforward; however, it is becoming increasingly apparent that it is associated with significant complications. One complication that has received relatively little attention is the neurological dysfunction that can occur due to the absence of the bone flap and the subsequent distortion of the brain under the scalp as cerebral swelling subsides. The aim of this narrative review was to examine the literature available regarding the clinical features described, outline the proposed pathophysiology for these clinical manifestations and highlight the implications that this may have for rehabilitation of patients with a large skull defect. METHODS A literature search was performed in the MEDLINE database (1966 to June 2012). The following keywords were used: Hemicraniectomy, decompressive craniectomy, complications, syndrome of the trephined, syndrome of the sinking scalp flap, motor trephined syndrome. The bibliographies of retrieved reports were searched for additional references. RESULTS Various terms have been used to describe the different neurological signs and symptoms with which patients with a skull defect can present. These include; syndrome of the trephined, posttraumatic syndrome, syndrome of the sinking scalp flap, and motor trephined syndrome. There is, however, considerable overlap between the conditions described and a patient's individual clinical presentation. CONCLUSION It is becoming increasingly apparent that certain patients are particularly susceptible to the presence of a large skull defect. The term "Neurological Susceptibility to a Skull Defect" (NSSD) is therefore suggested as a blanket term to describe any neurological change attributable to the absence of cranial coverage.
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Affiliation(s)
- Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital and Royal Perth Hospital, Western Australia
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Araujo Junior ASD, Arlant PA, Salvestrini A, Altieri CE, Santos JG, Pinto LF, Fazzito MM, Lee HW, Godoy LFDS. Asymmetric optic nerve sheath diameter as an outcome factor following cranioplasty in patients harboring the 'syndrome of the trephined'. ARQUIVOS DE NEURO-PSIQUIATRIA 2014; 71:963-6. [PMID: 24347017 DOI: 10.1590/0004-282x20130176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/27/2013] [Indexed: 11/21/2022]
Abstract
UNLABELLED Decompressive craniectomy (DC) is gaining an increasing role in the neurosurgical treatment of intractable intracranial hypertension, but not without complications. A rare complication is the "syndrome of the trephined" (ST). It occurs when the forces of gravity overwhelm intracranial pressures, leading the brain to become sunken. OBJECTIVE To determine the usefulness of asymmetric optic nerve sheath diameter (ONSD) as an outcome factor after cranioplasty. METHOD We followed-up 5 patients submitted to DC and diagnosed with ST. All were submitted to brain MRI to calculate the ONSD. RESULTS Only two patients presented an asymmetric ONSD, being ONSD larger at the site of craniectomy. Surprisingly these patients had a marked neurological improvement after cranioplasty. They became independent a week after and statistically earlier than others. CONCLUSION It is presumed that the presence of an asymmetric ONSD in trephined patients is an independent factor of good outcome after cranioplasty.
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Coelho F, Oliveira AM, Paiva WS, Freire FR, Calado VT, Amorim RL, Neville IS, de Andrade AF, Bor-Seng-Shu E, Anghinah R, Teixeira MJ. Comprehensive cognitive and cerebral hemodynamic evaluation after cranioplasty. Neuropsychiatr Dis Treat 2014; 10:695-701. [PMID: 24833902 PMCID: PMC4014378 DOI: 10.2147/ndt.s52875] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Decompressive craniectomy is an established procedure to lower intracranial pressure and can save patients' lives. However, this procedure is associated with delayed cognitive decline and cerebral hemodynamics complications. Studies show the benefits of cranioplasty beyond cosmetic aspects, including brain protection, and functional and cerebrovascular aspects, but a detailed description of the concrete changes following this procedure are lacking. In this paper, the authors report a patient with trephine syndrome who underwent cranioplasty; comprehensive cognitive and cerebral hemodynamic evaluations were performed prior to and following the cranioplasty. The discussion was based on a critical literature review.
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Affiliation(s)
- Fernanda Coelho
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | | | | | - Fabio Rios Freire
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Vanessa Tome Calado
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Robson Luis Amorim
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Iuri Santana Neville
- Division of Neurosurgery, University of São Paulo Medical School, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Neurosonology and Cerebral Hemodynamics Group, University of São Paulo Medical School, São Paulo, Brazil
| | - Renato Anghinah
- Neurorehabilitation Group, Division of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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Management of decompressive craniectomy defects: modern military treatment strategies. J Craniofac Surg 2013; 23:2042-5. [PMID: 23154344 DOI: 10.1097/scs.0b013e318258ba36] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Decompressive craniectomy has become a critical and standard life-saving maneuver in the theater of war. The high number of patients returning with large cranial defects and complex craniofacial injuries often involving the upper orbits or associated with the sunken skin flaps are a reconstructive challenge. We present a review of our treatment protocol highlighting the evolution of decompressive craniectomy and the development of a modern cranial defect treatment algorithmic approach to reconstruct these difficult clinical cases. METHODS A review of previously published data and current data from our warfare treatment unit that reported the treatment of decompressive cranial defects from 2004 to 2011 was performed. Reported data included mechanism of injury, evacuation time, initial Glasgow Coma Scale (GCS), GCS on arrival to the continental United States, type of decompressive craniectomy, type of implants used for reconstruction, and complications such as implant infections, exposures, and removals. Secondary reconstruction techniques used to salvage failed cranioplasty cases with free tissue transfers and cranial bone or dermal fat grafts as indicated were also reviewed and outcomes were reported. RESULTS From March 2003 to July 2011, more than 200 patients were identified who underwent cranioplasty after decompressive craniectomy. Patient average age was approximately 25 years (range, 18-53 y), and all patients were male. Average follow-up was 870 days (2.4 y). Average GCS at initial presentation was 7 and was 9 on arrival to the continental United States. Average time to evacuation to the continental United States was 6 days. Of all injuries, 46% were associated with an improvised explosive device blast. Of the patients, 90% underwent hemicraniectomies with the remaining 10% having received bifrontal craniectomies. Successful reconstruction and retention of the implant was present in 95% of the overall cohort. Contour abnormalities were the most common adverse outcome encountered (10% of patients after cranioplasty), whereas infections resulting in implant loss (5%) and seizures (<5%) were the most common complications that occurred after cranioplasty reconstruction. CONCLUSIONS Warfare-related decompressive craniectomy defects can be safely reconstructed using custom alloplastic implants with low morbidity and mortality. Risk factors that increase the rate of infection and require implant removal included orbital extension of the craniectomy defect, proximity to facial sinuses, and large contour abnormalities with corresponding large dead spaces. Staging reconstruction of high-risk cranial defects followed by definitive cranial defect reconstruction improved the likelihood of implant retention and successful cranioplasty outcome.
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Honeybul S, Janzen C, Kruger K, Ho KM. The impact of cranioplasty on neurological function. Br J Neurosurg 2013; 27:636-41. [DOI: 10.3109/02688697.2013.817532] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mak CHK, Lu YY, Wong GKC. Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage. Vasc Health Risk Manag 2013; 9:353-9. [PMID: 23874101 PMCID: PMC3714000 DOI: 10.2147/vhrm.s34046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Intracranial hypertension is commonly encountered in poor-grade aneurysmal subarachnoid hemorrhage patients. Refractory raised intracranial pressure is associated with poor prognosis. The management of raised intracranial pressure is commonly referenced to experiences in traumatic brain injury. However, pathophysiologically, aneurysmal subarachnoid hemorrhage is different from traumatic brain injury. Currently, there is a paucity of consensus on the management of refractory raised intracranial pressure in spontaneous subarachnoid hemorrhage. We discuss in this paper the role of hyperosmolar agents, hypothermia, barbiturates, and decompressive craniectomy in managing raised intracranial pressure refractory to first-line treatment, in which preliminary data supported the use of hypertonic saline and secondary decompressive craniectomy. Future clinical trials should be carried out to delineate better their roles in management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage patients.
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Mokri B. Spontaneous Low Pressure, Low CSF Volume Headaches: Spontaneous CSF Leaks. Headache 2013; 53:1034-53. [DOI: 10.1111/head.12149] [Citation(s) in RCA: 196] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Bahram Mokri
- Department of Neurology; Mayo Clinic; Rochester; MN; USA
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Advanced Cranial Reconstruction Using Intracranial Free Flaps and Cranial Bone Grafts. Plast Reconstr Surg 2012; 130:1101-1109. [DOI: 10.1097/prs.0b013e318267d5cb] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cranioplasty With Custom-Made Implants: Analyzing the Cases of 10 Patients. J Oral Maxillofac Surg 2012; 70:e169-76. [DOI: 10.1016/j.joms.2011.09.036] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2011] [Revised: 09/06/2011] [Accepted: 09/27/2011] [Indexed: 11/22/2022]
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