Pott's puffy tumour of the frontal and Parietal bones with subgaleal abscess as a complication of acute sinusitis - a case report

Acute sinusitis is a frequent medical condition that can affect any age group and may lead infrequently to very serious life-threatening complications. These complications include the spread of infection to frontal and other cranial bones, meninges, and other intracranial structures that require urgent medical actions to prevent mortality and morbidity. We report the case of acute frontal sinusitis in a 14 years old male who presented with fever, severe headache, and fluctuant swelling of the nasal root, and right supraorbital and frontoparietal regions. Imaging studies demonstrated signs of left-sided sinusitis, osteomyelitis of the frontal bones, and right parietal bone. Urgent surgery was performed with drainage of the abscesses and samples were sent for culture and sensitivity. Bilateral antral washout and trephination of the left frontal sinus was performed and pus was evacuated. Growth of Staphylococcus aureus and Peptostreptococcus micros was reported and according to the sensitivity report, the patient was kept on intravenous meropenem, 1500 mg per day and vancomycin 1500 mg per day was added on the 7th postoperative day. The patient was discharged from the hospital in good health on the 25th postoperative day and kept on oral vancomycin for one month.

Regenerative Effect of Resorbable Scaffold Embedded Boron-Nitride/Hydroxyapatite Nanoparticles in Rat Parietal Bone

BN has important roles in several physiological events, including bone growth and immune system. New infection-free cranioplasty and has an osteogenic activities material that are compatible with tissue are being developed. We aimed in our study to examine whether different combinations of Boron-nitride/Hydroxyapatite are embedded into the scaffold in the treatment of calvarial defects. 200 adult female Sprague-Dawley rats divided into 10 equal groups. Osteotomy was made by trepan drill in 8 mm diameter. The scaffolds were placed in the rats and were left to recovery for 2 months. During the experiment, CT scans were taken from the calvarial areas of the rats in the 2nd, 4th and 8th weeks. Significant healing was observed in defect diameters in 2.5% BN+10% HA, 2.5% BN and 5% BN+10% HA, respectively. After 8 weeks, it was seen that the amounts of OPN, BMP-2, RunX2 and ALP mRNA expression significantly decreased in 2.5% BN+10% HA, 2.5% BN, 5% BN+10% HA and 5% BN groups. It was shown that bone recovery was at the best grade in the groups, which contained 2.5% BN and 2.5% BN+10% HA when compared to the other groups. BN is a very promising agent that will be used in reconstructive surgery for the treatment of calvarial bone defects.

Subcutaneous Extension of Parasagittal Atypical Meningioma Through Parietal Foramen

Meningiomas extended to the scalp without any bony changes are rare. A 79-year-old man presented with a large subcutaneous mass in the midline parieto-occipital region and progressive right hemiparesis. The contrast-enhanced millimetric computed tomography scans of the head showed the intracranial parasagittal enhanced mass invading the superior sagittal sinus and the subcutaneous mass without any bony destructive, osteoblastic, or osteolytic changes. Under the operative microscope, no visible communication was found between the intracranial and extracranial mass lesions. Histopathologic examination of both intracranial and extracranial tumors demonstrated the same atypical meningioma (World Health Organization grade II). The possible route of extracranial extension of the tumor may be the sizable parietal foramen.

Intraosseous epidermoid cyst of the skull: case study and radiological imaging considerations

We report an atypical case of an epidermoid cyst associated with a skull defect to emphasize the diagnostic utility of bedside ultrasonography for the evaluation of subcutaneous scalp nodules. A 24-year-old woman presented with what appeared to be a benign cyst on the right parietal scalp. The cyst was first noticed one year prior to presentation and caused only mild irritation. Upon excision of the cyst, a notable calvarial defect was found in the frontoparietal bone and surgical excision was suspended. Head and brain imaging was performed confirming the calvarial defect with mild mass effect on the brain. A neurosurgical consultation was obtained, and the patient underwent craniotomy followed by cranioplasty with titanium plate placement. The histological evaluation confirmed the suspicion of an intraosseous epidermoid cyst. We hope to raise awareness of the potential for intraosseous involvement of otherwise routine scalp nodules and emphasize the utility of bedside ultrasonography as a quick, easy, and benign imaging modality to assist in preoperative evaluation.

Lipoedematous scalp: is there an association with fatty infiltration of the parotid?

Lipoedematous scalp (LS) is an extremely rare condition characterised by a soft and boggy consistency in the scalp due to an increased layer of subcutaneous tissue.In this report, we present a case of LS in a 64-year-old Indian woman. Clinical examination revealed only vague boggy lumpiness involving the whole of occipital scalp extending to parietal scalp. MRI scalp showed diffuse fatty infiltration of the scalp, particularly at the posterior parietal and occipital convexity extending to both lateral aspects of the cranium, with homogeneous signal in keeping with fat. Incidentally MRI also found diffuse fatty infiltration of the parotids.The aethiopathogenesis of LS is still unknown, however it is believed that the hormone leptin could be the key hormone in the dysregulation of fat deposition and distribution. This case report highlights the subtle features with which these cases can present and explores the literature on reported cases of LS.

Guided Bone Regeneration in Standardized Calvarial Defects in Rats Using Bio-Oss and β-Tricalcium Phosphate with Adjunct Platelet-Derived Growth Factor Therapy: A Real-Time In Vivo Microcomputed Tomographic, Biomechanical, and Histologic Analysis

The objective of the present real-time in vivo experiment was to assess guided bone regeneration (GBR) in standardized calvarial defects using particulate graft material (Bio-Oss) and β-tricalcium phosphate (β-TCP) with adjunct recombinant human platelet-derived growth factor (rhPDGF) therapy. Eighteen female Sprague-Dawley rats with a mean age and weight of 8 ± 0.53 weeks and 250 ± 0.49 g, respectively, were used. Following surgical exposure, a full-thickness standardized calvarial defect was created on the parietal bone using a trephine drill with an outer diameter of 4.6 mm. For treatment, rats were randomly divided into three groups (six rats per group): (1) control; (2) rhPDGF + Bio-Oss, and (3) rhPDGF + β-TCP. Volume of newly formed bone (NFB), bone mineral density (BMD) of NFB, volume of remnant bone particles, and BMD of remnant bone particles were assessed using in vivo microcomputed tomography. Measurements were made at baseline and at 2, 4, 6, and 10 weeks after the surgical procedures. At 10 weeks, all animals were sacrificed and calvarial tissues were assessed histologically. In the control group, a significant increase in BMD of NFB was observed at 6 weeks (mean ± standard deviation [SD], 0.32 ± 0.002 g/mm(3)) (P < .01) from baseline, and the defect did not regenerate completely. In the rhPDGF + Bio-Oss group, mean ± SD volume (2.40 ± 0.25 mm(3)) (P < .01) and BMD (0.13 ± 0.01 g/mm(3)) of NFB significantly increased at 4 weeks and 6 weeks, respectively, from baseline (P < .001). In the rhPDGF + β-TCP group, mean ± SD volume (2.01 ± 0.7 mm(3)) and BMD (0.12 ± 0.02 g/mm(3)) of NFB significantly increased at 4 weeks from baseline (P < .01). In the rhPDGF + Bio-Oss and rhPDGF + β-TCP groups, mean ± SD BMD of remnant bone particles (0.31 ± 0.11 g/mm(3) and 0.23 ± 0.01 g/mm(3)) showed significant reduction at 6 and 10 weeks, respectively, compared with baseline values (1.12 ± 0.06 g/mm(3) and 0.92 ± 0.01 g/mm(3), respectively) (P < .001). Histologic results at 10 weeks showed NBF in the rhPDGF + Bio-Oss and rhPDGF + β-TCP groups. In real time assessment, when rhPDGF was added to β-TCP, BMD and bone hardness significantly increased compared with the other two groups.

A wide skull ostelytic metastasis in advanced breast cancer

We present a case report of a large and deep osteolytic metastasis radiological documented involving the skull in a woman affected by advanced breast cancer during endocrine therapy.

[Extruded cochlear implant magnet covered with a temporoparietal fascial flap. A case report]

Complications are infrequent after cochlear implant surgery but they might occur despite careful preoperative planning and meticulous surgical technique. Among the most commonly encountered problems are those associated with the postauricular flap. An exposed, and therefore contaminated, device requires immediate attention and intervention. Cochlear implantation revision surgery is justified by two main reasons, the high price of these devices and the difficulty of reimplantation, due to cochlear fibrosis and ossification after its removal. There are multiple options in cochlear implantation revision surgery with infected device. However, the temporoparietal fascia flap is highly vascularized and provides some advantages over other alternatives. We report a case of a 5 year old boy with bilateral sensor neural hearing loss, who suffered a device extrusion three years after its implantation.

[Effect of endothelial progenitor cells mobilization on the healing of calvarial defect in diabetic mice]

OBJECTIVE

To evaluate the effect of endothelial progenitor cells (EPCs) mobilization on the healing of calvarial defect in diabetic mice.

METHODS

55 type II adult male diabetic mice were included in this study. They were randomly divided into three groups: the non-operative group (n = 5), the experimental group (n = 25) and the control group (n = 25). Two circular bony defects, 3 mm in diameter, were created on the parietal bones of the diabetic mice. Intraperitoneal AMD3100 (10 mg/kg; n = 25) or sterile saline (control group) was administered daily beginning at post-operative day 3 and continuing for 15 days. 5 mice were sacrificed in each group at non-operation, post-operative week 1,2,4, 8,12. Circulation EPC level was measured at pre-operation, post-operative day 7 and day 14. Bony regeneration was assessed with micro-CT at post-operative week 4, 8 and 12. HE staining was performed on all the decalcified bone samples. Immunofluorescent CD31 and osteocalcin staining was performed on calvarial defects at weeks 1, 2, and 4 to assess the vascularity and osteoblast density, respectively.

RESULTS

The mobilization of EPC in diabetic mice almost disappeared one week after trauma, while AMD3100 could dramatically increase the circulation EPC level for a long time after trauma. Compared to control group, the healing percentage of bony defect in the diabetic mice treated with AMD3100 was obviously increased at post-operative week 8 (50.5% vs. 34.8%) and week 12 (50.9% vs. 40.2%). Calvarial defects of AMD3100-treated mice harvested at 1, 2, and 4 weeks demonstrated increased vascularity and osteoblast density, compared to the controls. The difference was most marked in postoperative week 2 (vascularity: 6.11% vs. 2.47%; osteoblast density 2.81% vs. 1.22%, P < 0.01).

CONCLUSION

AMD3100 can improve the healing of calvarial defect in diabetic mice by increasing the vascularity and osteoblast density at the regeneration area.

Pericranium graft in reconstructive surgery of atrophied maxillary bones

In preprosthetic surgery the autologous bone is universally considered the gold standard. Calvaria is, among many options, one of the preferred for its unique characteristics of hardness, easy of harvest and very low morbidity at donor site. Moreover, it gives the possibility of harvesting the pericranium. This technique, recently introduced in common practice in Milan, allows to harvest a large quantity of periosteum to cover bone grafts perioperativly. Periosteal tissue is used to cover bone grafts for two reasons. First, it would provide a layer of tissue that, thanks to its osteogenic potential, would prevent bone resorption. Second, this would interpose a layer of soft tissue to act as a cushion between the bone and mucosal flap to minimize the risk of wound dehiscence, that would bring to bone exposure and consequent failure of reconstruction. Five jaw reconstructions were performed with autologous bone and pericranium. In all cases the outcome was good, the grafts took with correct bone volume preservation. Implants were positioned according to prosthetic needs. In one case a vascular necrosis of a mucosal flap occurred. Bone exposure was prevented by the periosteum, which was revascularized after few days, allowing bone integration. Considering its potential protective capability towards bone grafts and the lack of donor site morbidity, this technique should be considered as a standard procedure in preprosthetic reconstructive surgery.

Case report

Aneurysmal bone cyst is a benign lesion of unknown pathogenesis seen more often in vertebrae and flat bones, and less commonly in the shaft of long bones. Skull involvement is rare and accounts for only 3-6% cases, generally in the first three decades of life. Histologically, the lesion is characterised by the presence of multiple localisations, filled with venous blood and lined by spindle-shaped fibroblasts with scattered multinucleated giant cells and stromal cells. An unusual case of aneurismal bone cyst of the parietal bone is reported.

Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches

BACKGROUND

Endoscopic expanded endonasal approaches (EEAs) for the resection of lesions of the anterior and ventral skull base can create large defects that present a significant risk of postoperative cerebrospinal fluid (CSF) leak. These defects, especially in patients who received preoperative radiotherapy, are best reconstructed with vascularized tissue. The Hadad-Bassagasteguy flap, a pedicled nasoseptal flap, is our preferred method for reconstruction. This option is not available, however, in patients who underwent a previous posterior septectomy or in those with tumors that invade the pterygopalatine fossa (PPF) or sphenoid sinus rostrum. In this scenario, we have used a temporoparietal fascial flap (TPFF) for the reconstruction of large surgical defects.

METHODS

We developed a new technique for the transposition of the TPFF into the nasal cavity to reconstruct skull base defects after EEA. The flap is harvested using a conventional hemicoronal incision but is then advanced to the defect using a temporal-infratemporal tunnel and an endonasal transpterygoid approach. The latter is created using an endoscopic endonasal approach that involves the resection of the posterior wall of the antrum, dissection of the PPF, and partial resection of the pterygoid plates. These maneuvers open a bone window to accommodate the flap. The soft tissue tunnel, extending from the temporal to the infratemporal and then to the PPF, is opened with percutaneous tracheostomy dilators. We present a detailed description of the surgical technique and a retrospective review of two cases in which we used this technique.

RESULTS

Two patients with large CSF fistulas who had undergone preoperative radiotherapy were reconstructed transposing the TPFF through a transpterygoid tunnel. We obtained an adequate exposure for placing the flap endonasally, and the flap provided complete coverage of the skull base defect. Both CSF leaks were resolved without any additional morbidity from the flap or the access technique.

CONCLUSION

The TPFF is a reliable and versatile method for the reconstruction of the anterior, middle, clival, and parasellar skull base after EEAs. Its harvesting requires an external incision; thus, it is not our preferred method of reconstruction. It is recommended for large dural defects in patients with previous posterior septectomy and previous radiation treatment.

Calvarial versus iliac crest for autologous bone graft material for a sinus lift procedure: a histomorphometric study

PURPOSE

The aim of this study was to compare, through histomorphometric analysis, the use of donor autogenous bone graft from calvarial or iliac sources for maxillary sinus lift procedures.

MATERIALS AND METHODS

Sixteen patients requiring maxillary sinus augmentation were included in this study. One group of 10 patients was alternatively selected to receive autologous calvarial bone particles, and another group of 6 patients received autologous iliac bone particles. Five months after surgery, bone biopsy specimens were obtained at the time of implant procedure and analyzed through histomorphometry. To compare mean values between the calvarial and iliac crest groups, the Student t test was performed. The level for statistical significance was set at P < .05.

RESULTS

All patients completed the healing period following sinus augmentation procedure without complications. In the calvarial group, an average total bone volume (BV) of 73.4% +/- 13.1% was found. Nonvital bone constituted an average of 5.5% +/- 6.3% of the total tissue volume. The percentage of vital bone (VB) showed an average of 67.9% +/- 16.1%. In the iliac group, the average total bone volume was 46.6% +/- 17.4%, with an average of 12.6% +/- 7.7% of NVB and an average of 34.0% +/- 21.5% of VB. A significant difference was observed between calvarial and iliac bone grafts with respect to BV, VB, and NVB (P < .05).

CONCLUSION

From this present histomorphologic study, it might be concluded that grafted bone obtained from calvarial sources for sinus lift procedure presented a significantly higher degree of bone volume and vital bone volume in contrast to bone harvested from the iliac crest.

Transcranial puncture through the parietal and mastoid foramina for the treatment of dural fistulas

✓ In this report the authors describe the endovascular treatment of dural arteriovenous fistulas (DAVFs) through trans-cranial puncture of the feeding arteries. Four patients had DAVFs that were fed by occipital arteries (OAs) that supplied blood to the intracranial meningeal arteries via the transcranial branches and coursed through the parietal and mastoid foramina. Due to the excessive tortuosity of the OA, conventional endovascular navigation had failed in all cases. Transcranial puncture of the meningeal feeding arteries was performed through the parietal or mastoid foramen, allowing navigation with a microcatheter until the level of the shunts. Complete cure of the DAVF was attained in all patients after injection of acrylic glue.

Lateral impact in closed head injury: A substantially increased risk for diffuse axonal injury—A preliminary study

OBJECTIVE

Assessment, whether location of impact causing different facial fracture patterns was associated with diffuse axonal injury in patients with severe closed head injury.

METHODS

Retrospectively all patients referred to the Trauma Unit of the University Hospital of Zurich, Switzerland between 1996 and 2002 presenting with severe closed head injuries (Abbreviated Injury Scale (AIS) (face) of 2-4 and an AIS (head and neck) of 3-5) were assessed according to the Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS). Facial fracture patterns were classified as resulting from frontal, oblique or lateral impact. All patients had undergone computed tomography. The association between impact location and diffuse axonal injury when correcting for the level of consciousness (using the Glasgow scale) and severity of injury (using the ISS) was calculated with a multivariate regression analysis.

RESULTS

Of 200 screened patients, 61 fulfilled the inclusion criteria for severe closed head injury. The medians (interquartile ranges 25;75) for GCS, AIS(face) AIS(head and neck) and ISS were 3 (3;13), 2 (2;4), 4 (4;5) and 30 (24;41), respectively. A total of 51% patients had frontal, 26% had an oblique and 23% had lateral trauma. A total of 21% patients developed diffuse axonal injury (DAI) when compared with frontal impact, the likelihood of diffuse axonal injury increased 11.0 fold (1.7-73.0) in patients with a lateral impact.

CONCLUSIONS

Clinicians should be aware of the substantial increase of diffuse axonal injury related to lateral impact in patients with severe closed head injuries.

Objective evaluation of sylvian fissure development by multiplanar 3-dimensional ultrasonography

OBJECTIVE

Evaluation of fetal cerebral cortex sulcation is important for the pre-natal diagnosis of neuronal migration disorders. Although abnormal sylvian fissure morphologic features are frequently observed in these conditions, the diagnosis of an abnormal sylvian fissure relies on subjective interpretation of ultrasonographic images. This study was performed to develop an objective ultrasonographic parameter for sylvian fissure evaluation.

METHODS

This cross-sectional study included 202 normal singleton pregnancies without fetal anomalies. Using multiplanar, 3-dimensional ultrasonography, the sylvian fissure midpoint was identified. The sylvian fissure-to-parietal bone distance (SPB) was measured from the midpoint to the inner surface of the parietal bone, perpendicular to the falx cerebri. Bland-Altman plots were used to determine intraobserver and interobserver agreement. Regression analysis was used to evaluate the correlation between SPB measurements and gestational age.

RESULTS

Two hundred (99%) of 202 pregnancies had a visible sylvian fissure, identifiable as early as 12 weeks of gestation. The mean SPB values at 12 and 41 weeks were 2.1 and 14.3 mm, respectively. Intraobserver and interobserver mean differences between paired measurements were 0.01 mm (95% limits of agreement, -0.41 to 0.43 mm) and 0.05 mm (95% limits of agreement, -1.79 to 1.90 mm), respectively. A linear correlation was observed between the SPB and gestational age (multiple R=0.91; R2=0.82 [SPB = -2.85 + 0.42 x gestational age]).

CONCLUSIONS

(1) The SPB can be reproducibly measured from 12 weeks of gestation to term; and (2) a strong positive correlation was observed between the SPB and gestational age.

Bilateral parieto-occipital dermoid sinuses in a Rottweiler

Bilateral dermoid sinuses were identified on the parieto-occipital region of a Rottweiler. Diagnosis was confirmed by histological examination after successful complete surgical resection. The dermoid sinuses were independent with separate tracts. This unusual parasagittal location can be explained by craniofacial development: dermoid sinuses on the head could occur along the lines of embryological fusion and not only in the sagittal plane. A hypothesis of an origin at the level of the suture between the parietal and interparietal bones is possible in this case.

Recovery Course of Full-Thickness Skin Defects With Exposed Bone: An Evaluation by a Quantitative Examination of New Blood Vessels

BACKGROUND

Full-thickness skin defects with exposed bone are often hard to heal. The lack or delayed re-vascularization is considered one of the major causes, and the periosteum is also suggested to have an important role in tissue regeneration.

MATERIALS AND METHODS

Full-thickness skin defect wounds with exposed bone were made in the parietal region of Wister rats. The periosteum of the exposed parietal bone was removed in the periosteum-lacking group, but maintained in the control group (periosteum-intact group). The wound was covered by an artificial dermis made of collagen. The wound healing process was histologically compared. Double immunostaining of alpha-smooth muscle actin (SMA) and von Willebrand factor (vWF) was used for re-vascularization examination, and the blood vessel density in the artificial dermis was quantified.

RESULTS

The density of the blood vessels in the uninjured parietal tissue was approximately 80 vessels/mm(2). To reach this density, 7 and 21 days were required for the control (periosteum-intact) and the periosteum-lacking groups, respectively. This coincided with complete revascularization, fibroblast migration and the reentry of blood vessels to the upper layer of the wound were observed.

CONCLUSION

The described results support the importance of the periosteum in the full-thickness skin defect healing process.

Intradiploic epidermoid cyst with focal internal enhancement

We report a case of intradiploic epidermoid cyst with focal internal enhancement. The patient was a 55-year-old woman presenting with right temporal head protrusion and head heaviness. Skull radiography and computed tomography demonstrated an expansile mass in the right diploic space. On magnetic resonance imaging, the mass showed makedly high signal T2-weighted images (T2WI) and intermediate to low signal on T1WI. On contrast-enhanced T1WI, there was nodular internal enhancement, which corresponded to neovascularity on pathology, as well as rim-like enhancement. It should be noted that internal enhancement, an indicator of malignant transformation, may be seen even in a benign epidermoid cyst.

Xanthoma disseminatum of the central nervous system and cranium

Xanthoma disseminatum is a rare normolipemic histiocytic disorder of non-Langerhans cell origin. It is a chronic systemic disease with a benign course, characterized by disseminated, yellow-orange-colored papules on the face, flexures, and mucosal membranes. We report 3 patients with xanthoma disseminatum, who presented primarily with central nervous system disease and a multitude of imaging findings throughout the craniospinal axis.

Osteosarcoma presenting as a solitary focus of osteolysis in the calvarium

Osteolysis of the skull is fairly common. The clinical presentation and results of laboratory or imaging tests may suggest a benign or a malignant disease. However, histology is the only means of obtaining a definitive diagnosis and should therefore be performed at the slightest doubt. We report the case of a 58-year-old man who presented with a recent painless lump in the right temporoparietal region. Laboratory tests were normal. Brain imaging studies and total body radionuclide scanning showed no other lesions. However, the heterogeneous and aggressive appearance of the skull lesion prompted a surgical biopsy, which showed osteoblastic osteosarcoma. Chemotherapy and radiation therapy were given after complete excision of the tumor.

Temporoparietal fascia plication in rhytidectomy

BACKGROUND

The temporal region has a complex subcutaneous fascial structure known as the temporoparietal fascia, which is part of the subcutaneous musculoaponeurotic system. The temporoparietal fascia is continuous with the superficial musculoaponeurotic system (SMAS) of the face in the inferior border, the frontalis muscle, and the orbicularis oculi muscle in the anterior border. Therefore, a properly planned temporoparietal fascia plication can increase the tightness of the SMAS. In addition, plication of the temporoparietal fascia can provide lifting to decrease lateral canthal wrinkles with elevation of the lateral brows in rhytidectomy. Furthermore, plication of the temporoparietal fascia can yield deep tissue support, which prevents alopecia and visible scar formation in the temporal region by decreasing the tension along the skin incision.

METHODS

Plication of the temporoparietal fascia was performed for 16 patients who had undergone face-lifts over the previous 10 years. Careful subcutaneous dissection, performed immediately under the hair follicles to avoid frontal nerve injury, provides excellent exposure of the temporoparietal fascia for plication in rhytidectomy and protects the auriculotemporal nerve and the superficial temporal vessels.

RESULTS

There were no complications such as hematoma, facial nerve injury, alopecia, or visible scar formation attributable to the temporoparietal fascia plication.

CONCLUSION

Temporoparietal fascia plication can be performed simply during rhytidectomy as an additional procedure. It not only augments the effects of the rhytidectomy, especially in the lateral brows, the lateral canthal, and the temporal regions, but also decreases the risk of possible complications.

Radiation-Induced Osteosarcoma 16 Years After Surgery and Radiation for Glioma-Case Report-

A 35-year-old man developed osteosarcoma of the left parietal and occipital bones 16 years after radiotherapy for glioma in the right occipital lobe. Radiotherapy of the primary neoplasm used 50 Gy administered to a localized field through two lateral ports. The secondary neoplasm arose contralateral to the primary lesion but within the irradiated field. The tumor had a multilocular cyst with considerable intracranial extension, and symptoms of elevated intracranial pressure were prominent early in the course. After a short-lived initial remission following surgical intervention and chemotherapy, the patient deteriorated because of tumor recurrence and died 18 months after the diagnosis. Radiation-induced osteosarcoma is a well-known but rare complication of radiotherapy for brain neoplasms with a poor prognosis.

Giant ossifying chondroma of skull

We report a rare case of giant ossifying chondroma of skull arising from temporoparietal region in a 14-year-old female, which was successfully excised. While reviewing world literature few cases of extracranial chondromas arising from the skull base were found.

Osteopontin and bone metabolism: a histology and scintigraphy study in rats

Osteopontin (OPN) is one of the major non-collagen proteins in extracellular bone matrix. To elucidate the function of OPN in bone metabolism, a cellular defect was created in parietal bone and tibia of 12 rats. In Group 1, the left defects were filled with OPN-coated hydroxyapatite (OPN-H). In Group 2, the right defects were filled with non-coated hydroxyapatite (N-H). In both groups, the contra lateral defects were used as control defects. In Group 3, OPN-H was inserted in the left defects and N-H in the right defects. Bone metabolism was measured by (45)Ca and technetium-99m methylene diphosphonate scintigraphy for 4 weeks. Scintigraphy did not show any significant differences in bone metabolism between the defects filled with OPN-H and N-H. A higher bone metabolism was measured between the parietal defects filled with OPN-H or N-H in comparison with the parietal control defects. This difference, however, was not significant and was less for tibia defects. Histological observation (7th week) shows less inflammatory cells at the tibia defects filled with OPN-H compared to the tibia defects filled with N-H. This study did not show any acceleration or inhibition of bone metabolism in parietal or tibia bone in rats, but there is some evidence that OPN might influence inflammatory cells in bone matrix.

Thyroid cancer with skull enlargement: a lesson learned?

A case of endemic goitre associated with thyroid cancer and huge enlargement of the scalp is reported in a Brazilian mulatto from an iodine deficient Central west region of the country. On admission, osteolytic metastases of follicular thyroid carcinoma were found scattered in the parietal bones. Impressive images from old files could illustrate and emphasize the hurdle-like role of poverty and inadequate social and cultural attitudes before the fight against cancer in regions with limited resources. Even in developed countries, goitres still occur in areas with iodine prophylaxis. Another concern is insufficiency of reliable data on the incidence and pattern of head and neck tumours in developing countries.

[A rare case of chondromyxoid fibroma of the parietal bone]

The authors present a very rare case of the chondromyxoid fibroma (CMF) of the parietal bone. This is an uncommon chondroid tumour which constitutes less than 1% of primary bone tumours and which is usually localised in the metaphysis of the long bones, often in the knee region. There are 23 cases of cranial localisation of the chondromyxoid fibroma reported in several papers, 14 cases involved the cranial base and 9 the calvaria. A different ossification process of the skull-base and calvaria is probably responsible for this distribution. In our case we found the focal, lytic lesion in the parietal bone and fibro-greasy tumour mass. The dura was spared. The tumour was removed totally. Curettage of these kind of lesions should be avoided because it may lead to tumour recurrence. Histologically this tumour may cause problems in a differential diagnosis with other chondroid tumours like chondrosarcoma or chondroblastoma.

Infected cephalohematoma of newborns: experience in a medical center in Taiwan

BACKGROUND

The objective of the present retrospective study was to clarify the clinical course, major pathogens, and other infections associated with infected cephalohematoma.

METHODS

From January 1978 to December 2003, records of all newborns were reviewed for evidence of an infected cephalohematoma, based either on local signs of infection or a diagnostic tap that yielded pus. Patients were divided into two groups: those seen in the early period (1978-1990) and in the late period (1991-2003).

RESULTS

Twenty-eight newborns with infected cephalohematoma were identified, 14 each in the early and late periods. The mean age at onset was 17.8 +/- 13.9 days. The most common local findings were erythema (79%), increasing size of the hematoma (68%), and a fluctuant mass (46%), while fever (64%), poor appetite (39%) and irritability (18%) were the common systemic signs. Common laboratory findings included leukocytosis (82%) and an elevated C-reactive protein (61%). Escherichia coli was the most common pathogen (16 patients, 57%) and was isolated significantly more frequently in the late period (early period: 36%, late period: 79%, P < 0.05). Staphylococcus aureus was the second common pathogen (five patients, 18%). Ten patients (36%) had other associated infection: eight had sepsis, three had meningitis, and one had osteomyelitis. In the early period three patients (11%) died.

CONCLUSIONS

Clinicians should be aware that cephalohematoma is a potential site of infection. The incidence of associated system infection is high and may result in mortality. Appropriate diagnostic and therapeutic measures should be undertaken promptly if there are infectious signs.

P253R fibroblast growth factor receptor-2 mutation induces RUNX2 transcript variants and calvarial osteoblast differentiation

Unregulated fibroblast growth factor 2 (FGF2) signaling caused by mutations in the fibroblast growth factor receptor (FGFR2) leads to human craniosynostosis such as the Apert syndrome. In an in vitro control model of calvarial osteoblasts from Apert patients carrying the FGFR2 P253R mutation, we studied the changes in cellular phenotype and evaluated the effects of FGF2. Compared with wild-type controls, osteocalcin mRNA was down-regulated in Apert osteoblasts, Runt-related transcription factor-2 (RUNX2) mRNA was differentially spliced, and FGF2 secretion was greater. Total protein synthesis, fibronectin and type I collagen secretion were up-regulated, while protease and glycosidase activities and matrix metalloproteinase-13 (MMP-13) transcription were decreased, suggesting an altered ECM turnover. Adding FGF2 increased protease and glycosidase activities and down-regulated fibronectin and type I collagen secretion in Apert osteoblasts. High affinity FGF2 receptors were up-regulated in Apert osteoblasts and analysis of signal transduction showed elevated levels of Grb2 tyrosine phosphorylation and the Grb2-p85 beta association, which FGF2 stimulation strongly reduced. All together these findings suggest increased constitutive receptor activity in Apert mutant osteoblasts and an autocrine loop involving the FGF2 pathway in modulation of Apert osteoblast behavior.

Cranioplastie par lambeau libre ostéomusculaire temporo-pariétal

PURPOSE

Advances in composite materials for craniofacial reconstruction surgery has tended to limit indications for osteomuscular free flaps which nevertheless must be used for certain septic patients. The purpose of this report was to illustrate the usefulness of the free temoroparietal osteomuscular flap in this particular situation.

CASE REPORT

A 47-year-old man underwent surgical repair of an aneurysm of the anterior communicating artery complicated by acute hydrocephaly treated by external then ventriculoperitoneal bypass. The fronto-pteryonal approach was used. The early postoperative period was complicated by osteitis of the cranial piece requiring revision. The revision procedure, performed at the end of the septic period, involved cranioplasty with acrylic cement. Recurrent infection contraindicated any new attempt for prosthetic repair. The patient was treated with a controlateral free temporoparietal osteomuscular flap to achieve cranioplasty. The postoperative period was uneventful with no infection and satisfactory healing. Flap vitality was very satisfactory. The patient's neurological status improved and no further complication developed.

DISCUSSION

In certain therapeutic situations, several diffent techniques may be required to overcome postoperative complications or manage particularly difficult cases. A free osteomuscular flap can be a useful alternative for cranioplasty. This technique is rarely used but can offer an optimal solution in selected patients, particularly for second intention revision after failure of prosthetic repair.

Ossifying Fibroma of the Skull: Interactive Image-Guided Minimally Invasive Localization and Resection

Ossifying fibroma is a benign fibro-osseous tumor commonly affecting the craniofacial bones. It is considered to be a locally aggressive and quickly expansible bone lesion. Because of its aggressive nature and high recurrence rate, early detection and complete surgical removal are essential. Usually, these lesions are excised extensively by craniectomy, and bone loss is reconstructed by cranioplasty using acrylic resin or titanium implants. Alternatively, in the management of skull-ossifying fibroma, an image-guided technique using surgical navigation may provide precise information about localization, enabling complete removal, thereby operating with minimal exposure and within narrow resection borders and avoiding significant bone deformity. A 39-year-old male patient with a history of renal cell carcinoma was admitted to our hospital because a radionuclide scintigraphic bone scan revealed increased uptake in a small area located at the left lateral skull bone. The high-resolution computed tomography scan showed that the lesion was located inside the diploe, destroying the inner table of the calvarium. The patient underwent minimally invasive bone lesion removal using an interactive image-guided approach. Complete resection of the neoplastic lesion was achieved. The histopathological examination revealed an ossifying fibroma. The postoperative course was uneventful, and the patient was discharged 3 days after intervention. To date, there has been no evidence of local recurrence. Interactive multimodal planning and intraoperative image guidance offer an interesting approach for biopsy and minimally invasive removal of small ossifying fibroma lesions of the skull, especially in less accessible locations.

Bone augmentation osteogenesis using hydroxyapatite and beta-tricalcium phosphate blocks

PURPOSE

In this study, we investigated the differences in osteogenesis and resorption between hydroxyapatite (HA) and beta-tricalcium phosphate (beta-TCP) implanted on the parietal bone of rats.

MATERIALS AND METHODS

HA and beta-TCP were used in blocks with macropores and micropores. They were implanted between the parietal bone and the cranial periosteum in rats. Osteogenesis around the implanted materials was investigated histopathologically and histomorphometrically at 1, 2, 4, 8, and 24 weeks after surgery.

RESULTS

At 2 weeks, osteogenesis from the parietal bone was observed around both materials, and new bone had attached directly to the surfaces of both materials. New bone grew into the pores of the upper regions of both materials with time. The beta-TCP block had a characteristic basophilic reticular structure in which the dissolution of the materials was observed close to the new bone. The HA blocks were stable for 24 weeks, whereas parts of the beta-TCP blocks were fractured and resorbed at 24 weeks. Histomorphometrically, the volume of new bone around HA was larger than that around beta-TCP. There was no remarkable change in the amount of remaining HA, but that of beta-TCP was decreased.

CONCLUSION

HA blocks in this model are suitable for onlay grafts because of its stability and osteogenesis, beta-TCP is not stable. Therefore, when beta-TCP blocks are used for onlay grafts, the mechanical stress on the recipient site should be taken into consideration because of resorption and fracture.

[Diploic epidermoid cyst: case report]

We report the case of a diploic epidermoid cyst in the left front-parietal bone of a 70-year-old woman. A skull x-ray showed an osteolytic lesion with a sclerotic border, and CT scan revealed a low/iso-density mass and the destruction of both inner and outer tables. MRI showed hypo-intensity on T1-weighted image, hyper-intensity on T2-weighted imaging and remarkably-strong intensity on the diffusion-weighted imaging. Gadolinium enhancement was seen in the tumor capsule and dura of the peripheral tumor. In the operative view, most of the bone edge was regular with a sclerotic border, but an irregular section was present. The tumor adhered strongly to the dura mater and periosteum. The tumor was totally extirpated with the peripheral skull, dura mater and periost. On the postoperative MRI, gadolinium enhancement of the nearby dura mater and disappeared. We have added a discussion of the radiological features of diploic epidermoid cysts.

Transcriptional and post-transcriptional regulation of transforming growth factor beta type II receptor expression in osteoblasts

Variations in transforming growth factor beta (TGF-beta) activity depend on the expression of specific receptors in normal as well as transformed cells. For example, in addition to mutations in TGF-beta type II receptor (TbetaRII) that abrogate normal TGF-beta function, its expression decreases during the transition from replication to extracellular matrix production, or in response to other growth regulators in bone. Therefore, to understand how TbetaRII expression is controlled, we cloned the rat TbetaRII gene promoter and defined basic aspects of its structure and activity. Among several cis-acting elements, mutations within an upstream E-box that specifically binds USF nuclear factors or a downstream Sp1 binding site significantly reduced TbetaRII promoter activity in primary cultures of fetal rat osteoblasts. Treatment with bone morphogenetic protein 2 (BMP-2), which induces further osteoblast differentiation, significantly reduced cell surface TbetaRII. However, BMP-2 did not alter TbetaRII promoter activity, steady state TbetaRII mRNA, or total TbetaRII protein, but caused an intracellular relocation of TbetaRII. Select transcriptional elements thus regulate TbetaRII gene expression, whereas post-translational events controlled by BMP-2 rapidly modify the amount of TbetaRII protein on the bone cell surface. Consequently, several processes can alter functional TbetaRII levels in order to regulate the biological effects of this important growth factor.

Numular headache: a coin-shaped cephalgia

Numular headache is a chronic, mild to moderate, pressurelike pain in a circumscribed cranial area of approximately 2 to 6 cm in diameter. Pain usually is limited to the parietal region, although it may appear in any cranial site. It is a benign process of usually unknown origin.

Venous drainage architecture of the temporal and parietal regions: anatomy of the superficial temporal artery and vein

Anatomy of the superficial temporal artery and vein was analyzed with arteriograms, venograms, and arteriovenograms of fresh cadavers that had been injected with contrast medium. The superficial temporal artery always divided into two major branches: the frontal and parietal branches. However, the superficial temporal vein divided into one, two, or three major branches. The distribution area of the major branches of the superficial temporal vein was larger than that of major branches of the superficial temporal artery, and arteriovenograms clearly demonstrated that, except for its proximal portion, the superficial temporal vein was independent of the superficial temporal artery. The frontal and parietal branches of the superficial temporal artery had thin venae comitantes that originated from the proximal portion of the superficial temporal vein, and the venae comitantes gave off branches toward the skin and the underlying soft tissue. Branches to the skin anastomosed with a superficial venous network in the skin layer, which was formed by ramifications of the superficial temporal vein. The venous architecture of the temporal and parietal regions consisted of cutaneous veins and venae comitantes and was basically similar to that of the forearm and scapular region.

Solitary plasmacytoma of the skull bone

Solitary plasmacytoma of the bone is an uncommon variety of plasma cell tumour. Here an interesting case of solitary plasmacytoma of the skull bone, which is extremely rare, is being reported.

Adamantinoma and meningioma occurring synchronously in a patient with breast cancer: a case report

Screening mammography of a woman with no symptoms led to the diagnosis of carcinoma of the breast, an intracranial meningioma, and adamantinoma of the right tibia. This is the first reported case of three synchronous primary tumors of different tissue origins. Biopsy is essential for diagnosing or excluding primary tumor(s) in cases of suspected metastases occurring at a limited number of sites.

Fibrous dysplasia involving the skull base and temporal bone

OBJECTIVE

To gain a broader appreciation of the clinical presentation, operative treatment, and outcome of patients with fibrous dysplasia involving the skull base.

DESIGN

Retrospective review of a clinical case series.

SETTING

A single tertiary academic medical center.

PATIENTS

Twenty-one patients with histopathologically confirmed fibrous dysplasia involving the skull base cared for over a 15-year-period (1983-1998).

MAIN OUTCOME MEASURES

Clinical and radiographic location of the fibrous dysplasia lesions within the skull base, clinical presentation, surgical intervention, and clinical outcome were tabulated for each patient.

RESULTS

The ethmoids were most commonly involved (71%), followed by the sphenoid (43%), frontal (33%), maxilla (29%), temporal (24%), parietal (14%), and occipital (5%) bones. The most common presenting features included atypical facial pain and headache, complaints referable to the sinuses, proptosis and diplopia, hearing loss, and facial numbness. Surgical treatment, guided by clinical presentation, ranged from simple biopsy with conservative follow-up to craniofacial resection.

CONCLUSIONS

Fibrous dysplasia can present in myriad ways within the skull base. Modern imaging modalities and histopathologic analysis have made diagnosis relatively straightforward. Surgery, particularly in such a challenging region as the skull base, should be reserved for patients with functional impairment or a cosmetic deformity. Because of the benign nature of the condition, the surgery itself should be relatively conservative, with the primary goal being preservation of existing function.

Free temporoparietal fascial flap for coverage of a large palmar forearm wound after hand replantation

A free temporoparietal fascial flap with a split-thickness skin graft was used to cover a large palmar forearm wound in a patient whose hand had been replanted 21 days earlier after traumatic amputation at the distal forearm level. At a 39-month follow-up, the patient had achieved an excellent cosmetic and functional result, with no alopecia or facial nerve injury. The flap is advantageous for coverage of wounds that require a large amount of thin, pliable tissue, and it leaves a concealed donor-site scar.

Malignant giant-cell tumor of the parietal bone: case report and review of the literature

OBJECTIVE AND IMPORTANCE

Giant-cell tumors (GCTs) are primary bone tumors that involve long bones in 75 to 90% of patients. They seldom develop in the cranium and are very rare in patients older than 60 years of age. A GCT rarely occurs with Paget's disease; when it does, however, it is most commonly associated with the polyostotic form and tends to involve the craniofacial bones. Pagetic GCTs are less aggressive than GCTs that are not associated with Paget's disease.

CLINICAL PRESENTATION

We report the case of an 81-year-old woman with a painless left parietal mass and asymptomatic monostotic parietal Paget's disease.

INTERVENTION

Surgical resection was performed, and histological examination of the lesion demonstrated Paget's disease with a malignant GCT. An incidental, low-grade, small-cell lymphocytic lymphoma also was noted. The patient experienced local recurrence of the malignant GCT and eventually died after developing pulmonary metastases of the malignant GCT.

CONCLUSION

This case is the first reported example of a patient with a malignant GCT of the cranium associated with monostotic Paget's disease. It provides evidence that not all pagetic GCTs in the cranium are benign, as has been reported.