Custom made cranioplasty prostheses in porous hydroxy-apatite using 3D design techniques: 7 years experience in 25 patients

BACKGROUND

None of the materials currently used to reconstruct skull defects is fully satisfactory. Their biological and physical properties are very different to those of natural bone. Solid state, high porosity hydroxy-apatite (HA) seems to be a good support for bone regeneration within the prostheses, enabling integration of the heterologous material with low post-implant infective risk.

MATERIALS AND METHODS

A model of the cranium of each patient was made in epoxy resin by stereolithography. The prosthesis was built on this model using a ceramic sintering process. In each case, an exact copy of the missing bone flap was obtained (curvature, dimensions, margins, irregularities and thickness). The porosity obtained is the same as that of the spongy bone of the skull with interconnected macropores (>150 microm) to promote osteoblast migration into the prosthetic core. In The Neurosurgery Division of Cesena, 26 cranioplasty prostheses have been implanted with this technique in 7 years (from 1998 to 2004). No particular criteria were pre-established, but the main indications for use of ceramic prostheses were complex and/or extended (surface >25 cm(2)) post-surgery craniolacuna and/or previous unsuccessful procedures due to rejection, infection or bone flap reabsorption.

RESULTS

Twenty-five patients were included in this study. A clinical check-up and 3D CT (mean follow-up 30 months, range 12-79) always showed an excellent aesthetic result. No cases of infection, rejection or spontaneous prosthesis fragmentation were found. The surgical procedure was simpler and shorter than for other described procedures.

CONCLUSIONS

Bioceramic porous hydroxy-apatite prosthesis have been demonstrated as a valid alternative to traditional cranioplasty techniques both aesthetically and in terms of absence of infections/rejections. Principal limitations for the use of HA prostheses are the need for stereolithography process, the poor malleability of the material and the high cost.

Segregation analysis of migraine in 128 families

To test the existence of inherited liability to migraine, formal segregation analysis of family data collected from 128 patients has been performed. Patients were subdivided into three groups in accordance with the presence or absence of migraine in their parents. The results obtained in each group were then compared with those expected on the basis of two different modes of simple Mendelian inheritance, namely autosomal dominant and autosomal recessive transmission. Our data show that neither of the two hypotheses can be accepted, thus suggesting the existence of a possible genetic heterogeneity of liability to migraine.

Extradural haematomas: how many deaths can be avoided? Protocol for early detection of haematoma in minor head injuries

Since 1988 in the referral area of the Neurosurgical Unit of Cesena, Italy, a protocol for prevention of deterioration in minor head injury was adopted. Adult patients admitted to any hospital with a GCS score of 15 and 14 (transient) without neurological deficit are submitted to skull x-ray: if a fracture is present the patient is sent for CT to the nearest regional Center. In children skull x-ray is not routinely performed and the patients are admitted for observation to the nearest regional hospital. To assess the effects of such a protocol on morbidity and mortality of extradural haematoma (EDH), from June 1989 to September 1991 a consecutive series of 95 patients harbouring a significant acute EDH was collected. Mean age was 31 years; in 70% trauma was caused by a road traffic accident. The patients were divided into 3 categories: a) Clinical deterioration: mean GCS at surgery was 7.7; out of 27 patients, 12 had anysocoria and 3 bilaterally fixed pupils; the outcome showed only two deaths, one related to the EDH and the other to cardiac arrythmia. Most of the patients deteriorated either during transport after being recognized as at risk or already in Neurosurgery allowing rapid surgical treatment. b) Impaired consciousness (18 cases) and c) Minor head injury (50 cases) are groups of patients treated without morbidity and mortality. If we compare these results with those of a previous study of our group done in 1980-86, there is a statistically significant difference concerning both mortality and morbidity. Our protocol proved therefore to be adequate in preventing most deaths that occurred following clinical deterioration in an apparently low risk patient.

Skull fracture as a factor of increased risk in minor head injuries. Indication for a broader use of cerebral computed tomography scanning

Two series of patients with a minor head injury (for a total of 182 cases), differing only in the presence and absence of a linear skull fracture, were admitted to a nonspecialized hospital and prospectively examined by computed tomography scanning. The presence of a fracture line proved to be significant, inasmuch as it was accompanied by approximately 38% of intracranial abnormalities versus 6% in the nonfracture cases. Early detection of any intracranial pathology that was still asymptomatic allowed prompt transfer of patients to the neurosurgical center, where operative treatment was carried out, when indicated, without mortality or morbidity. All operations (11 cases) were performed on patients with a fracture (105 cases) whereas none of the nonfracture patients (77 cases) required surgery. It is proposed that adult patients with minor head injuries with a skull fracture be submitted to computed tomography scanning in order that intracranial lesions may be detected, and treated, before the onset of clinical deterioration.

Integration of image transmission into a protocol for head injury management: a preliminary report

Neurosurgical care is limited in many parts of the world to one or two hospitals serving a large geographic area. The quality of neurosurgical response to emergencies depends on the reliability and completeness of the information received from referral hospitals. The aim of this study is to show how application of guidelines for head injury management in an entire area can be usefully combined with transmission of images from the peripheral to the central hospital. From January 1998 to December 2000, 1665 CT examinations were sent via image transfer to the Neurosurgical Unit; 637 first examinations (47%) and 206 second examinations (70%) were related to acute trauma cases. Out of 637 first examinations, 150 patients were actually transferred to the Neurosurgery Unit (23%), whereas of 206 second examinations, only 10 patients were secondarily transferred (5%). In the absence of the outcomes of patients located outside the Neurosurgical Unit, we studied in detail these 10 patients. They are, in fact, the only way for us to partially measure the impact of our system. Only in a single case could the death be attributed to a delay in transferring the patient. We then studied the factors influencing the decision of patient transfer. Mean GCS was 11 both for transferred and non transferred cases. The mean age of all patients was 52 years (median 48, SD 20.5 years); mean age of non-transferred patients was 54 years and for transferred patients it was 41 years (p < 0.01). The same statistically significant difference concerning age applied to any type of pathology sent via image link. In conclusion our data show that it is feasible to co-ordinate in an entire area the treatment of head injured patients. Available systems for CT images link are reliable and mostly useful. Unnecessary transfers can be avoided and the neurosurgeons can evaluate the images of a number of patients who have always been treated outside our Units. This results in more work for the neurosurgeons on duty, but also in a better quality service for the whole area. The lack of follow-up for patients not admitted to Neurosurgery is the limitation on a quality assessment of the system.

Diagnostic value of peripheral blood T-cell activation and soluble IL-2 receptor for acute rejection in liver transplantation

BACKGROUND

T-cells play an important role in the pathogenesis of rejection. Monitoring T-cells activation markers in peripheral blood may contribute to diagnosis of acute rejection after liver transplantation (LTX).

METHODS

Lymphocyte subset distribution, expression of T-cell activation markers (flow cytometry), concentration of soluble (s) interleukin-2 receptor (IL-2R) (solid phase chemiluminescence immunoassay), and liver enzymes as well as bilirubin were prospectively tested in peripheral blood samples of LTX patients with (n=69) and without acute rejection (n=50). Acute rejection was assessed by standard criteria including liver biopsies.

RESULTS

Intra-individual monitoring of immune parameters revealed an up-regulation of IL-2 receptor (CD25) expression on CD4 and CD8 T-cells together with increases in sIL-2R levels in patients with acute rejections. Measuring sIL-2R levels resulted in highest diagnostic efficiency (>85%). This level of diagnostic efficiency was not reached by any other marker tested. From all conventional markers of hepatocellular integrity and function, alkaline phosphatase reached the highest level of diagnostic efficiency with 70%.

CONCLUSIONS

Monitoring of up-regulation of the IL-2/IL-2R pathway represents a useful tool for assessment of acute rejection after LTX.

Management of low-risk head injuries in an entire area: results of an 18-month survey

All patients admitted following a minor head injury (GCS is without neurological deficits) during an 18 month period in an entire area were submitted to the same diagnostic and therapeutic protocol. Adult patients were x rayed and in the cases with skull fracture (even asymptomatic), a computed tomographic (CT) scan was performed. Children (below the age of 14) did not routinely receive skull X-rays but were admitted to one of the five regional hospitals where a CT scanner was available 24 hours per day. Neuroradiologic investigations (carried out in over 600 patients) showed posttraumatic lesions in 201 cases; 113 of these patients were transferred to the neurosurgical center. There were 49 patients with extradural hematomas, 41 with brain contusions, 17 with depressed skull fractures, and six with subdural hematomas. Of these 113, 40 patients were operated on (mainly extradural hematomas); surgical indications were based on appearance of clinical deterioration, lesion volume, presence of midline shift, and/or compressed third ventricle and basal cisterns. In eight cases there was a clinical deterioration to a GCS of 13 or less; in all of these patients, the CT diagnosis (and transfer to a neurosurgical center, preceded the onset of deterioration. All patients admitted to such a center had a good outcome, but a survey of deaths related to head injury in the area revealed two fatalities following minor head injury. The only avoidable death was a patient with multiple brain contusions who developed sudden brain swelling on day 12 post-trauma. We conclude that, even if management mortality is not zero, our protocol is sufficiently safe for the treatment of minor head injury.

Giant sacral schwannoma: removal by an anterior, transabdominal approach

We report a case of a giant intrasacral schwannoma expanding into the presacral space. 'En bloc' resection was accomplished by an anterior, transabdominal approach. The advantages of such a procedure are discussed.

Rapid spontaneous disappearance of an acute extradural hematoma: case report

The authors report the case of a patient presenting with an acute extradural hematoma and diffuse axonal injury. Control CT scan performed 4 hours later showed the complete resolution of the extradural collection together with increased evidence of shearing injuries. The mechanism of the hematoma resolution may probably be related to the concomitant acute brain swelling.

Late recurrence of bleeding in a chronic extradural hematoma

Recurrence of bleeding from the inner capsule occurred in a chronic extradural haematoma in a 15-year-old boy 4 months after the original trauma. The case is presented to emphasize the potential hazards of nonsurgical treatment of chronic extradural hematomas.

CD3+ CD57+ lymphocytes are not likely to be involved in antigen-specific rejection processes in long-term allograft recipients

Cytofluorometric investigation of peripheral blood lymphocytes in 380 long-term (greater than 1 year posttransplantation) allograft recipients showed a significant increase in the proportion of CD3+57+ lymphocytes (greater than 20%) in 20% of patients with renal allografts, 66% of patients with cardiac allografts and 44% of patients with liver allografts. Most of these CD3+57+ cells expressed the CD8 antigen and a variable proportion the HLA-DR antigen. A retrospective analysis showed a poorer prognosis for the clinical outcome in those patients with elevated numbers of CD3+57+ cells in peripheral blood. However, CD57+ lymphocytes could rarely be detected in renal infiltrates by immunohistology. Using the Southern blot technique to analyse the T cell receptor rearrangement of separated CD57+ cells, no clonal or oligoclonal expansion of T cell clones could be detected. Nevertheless, there might be a bias towards the use of particular TCR-V beta gene families in at least some patients, as shown by analysis with monoclonal antibodies. In summary, CD57+ T cells are not likely to be directly involved in the rejection process. The data support the idea of a polyclonal and/or superantigen-driven expansion, but not of an antigen-driven expansion of these cells.

Asymptomatic acute bilateral epidural hematoma: results of broader indications for computed tomographic scanning of patients with minor head injuries

The authors report the case of a patient with an apparently minor head injury in whom broader indications for computed tomographic (CT) scanning allowed the early detection and treatment of an acute bilateral extradural hematoma. CT scanning of adult patients with linear skull fractures should be done whenever possible.

Portal vein angioplasty using a transjugular, intrahepatic approach for treatment of extrahepatic portal vein stenosis after liver transplantation

Symptomatic portal vein stenosis is an uncommon complication after liver transplantation. Portal vein angioplasty has been successfully established for treatment of portal vein stenosis using mesenteric or percutaneous, transhepatic approaches. We herein report on a patient who suffered from variceal bleeding due to portal hypertension 3 months after liver transplantation. After successful endoscopic sclerotherapy, an extrahepatic portal vein stenosis was diagnosed, and portal vein angioplasty was considered as primary therapeutic option. Instead of mesenteric or percutaneous, transhepatic approaches, we adopted a transjugular, intrahepatic access to introduce a 14-mm balloon catheter into the portal vein. Using this technique, angioplasty was successfully performed. After intervention, no further episodes of variceal bleeding occurred. We favour the transjugular, intrahepatic technique for portal vein angioplasty because it does not require general anesthesia, in contrast to the mesenteric approach, and it reduces the risk of intra-abdominal bleeding, compared to the percutaneous, transhepatic approach.

Cerebrovascular insufficiency secondary to extrinsic compression of the internal carotid artery by a fibrous band. Case report

We describe the case of a woman with positional transient ischemic attacks related to extrinsic compression of the internal carotid artery by a taut fibrous band between the sternocleidomastoid muscle and the carotid sheath.

Changes in the phenotype of polymorphic plasma proteins after liver transplantation - new data and medico-legal consequences

The genetically inherited polymorphic plasma protein types have always been considered stable for lifetime in humans. Most of these proteins are synthetised in the liver. Phenotypes for 14 plasma proteins in donors and recipients of liver transplants prior to and after transplantation were determined in 15 patients who had undergone liver transplantation at the university hospitals Charité and Rudolf Virchow in Berlin. The plasma proteins investigated were HP, TF, GC, PI, ORM1, ITI, A2HS, PLG, FXIIIB, BF, C3, C6, C8 and FH. Evidence was provided of irreversible change from the recipient type to the donor type in at least one patient for all the systems investigated. This is the first time such data have been obtained for ITI, A2HS, C8 and FH. These results clearly support the point that the dogma of life-long stability of genetically determined protein phenotypes is merely of limited validity. Against the background of good long-term results of liver transplantation, there are consequences for the practice of legal medicine in the particular context of certification of parentage, identification and stain analysis.

Quantitative alterations of immune serum globulin concentrations in pigs transplanted with a renal allograft

The variation of immune serum globulin concentrations in 14 pigs was determined after unilateral allogenic renal transplantation. Measures by which it is possible to exert certain immunological influences were not taken. Subsequent to transplantation there was observed a significant decrease in both IgM and IgG which was not correlated with the behaviour of plasma proteins and albumin. Because of the relatively small loss of IgG in the urine of animals on which transplantations were performed, this cannot be considered to be the cause of the decrease in immunoglobulin. It was already on the 3rd day after transplantation that an increase in IgM was observed which after reaching a peak of about + 30% was again followed by a distinct decrease of which the minimum was noted between the 6th and 15th days after transplantation. 10 animals died within the first phase, and in 4 of them death occurred on account of rejection for which histological evidence could be obtained. Although 3 of the 4 animals surviving for a longer period of time were also observed to suffer from distinct rejective crises between the 8th and 15th day after transplantation, they were able to overcome those crises without any therapeutical intervention. After some time, however, they were experiencing another IgM peak (this time greater than + 80%) which was followed, after 3 to 11 days, but the final crisis of rejection and death of the animal. In a few cases, glomerular IgM deposits were found in transplanted kidneys.

Neuropathy caused by spontaneous intraneural hemorrhage: case report

A case of ulnar neuropathy at the elbow produced by spontaneous intraneural hemorrhage in a patient with acquired immunodeficiency syndrome and thrombocytopenia is reported. Intraneural hemorrhage in patients with bleeding disorders occurs infrequently. It consists of acute intrafascicular bleeding, presumably producing very high elevations of endoneurial fluid pressure. The clinical features and treatment of this condition are considered, the pertinent literature is reviewed, and the involved pathophysiological mechanisms are discussed.

[Blood specimen collection and liver biopsy in miniature swine]

The collection of investigational material means a problem occasionally during long-term observations of experimental animals. The described methods for punction of the superior vena cava and the percutaneous liver biopsy by means of a prostatic biopsy needle in miniature swine are carried out easily by one examinator without auxiliary personnel. Sufficient investigational material of good quality is to receive. Complicating factors are shown.

Cytomegalovirus infection in transplant recipients. The role of tumor necrosis factor

Human cytomegalovirus (CMV) infection is an important cause of morbidity and mortality in transplant recipients. CMV infection commonly results from the reactivation of a latent infection. Using a set of monoclonal anti-CMV antibodies, we found CMV antigen expression in peripheral blood mononuclear cells (PBMNC), particularly in monocytes, in 312 of 816 samples from 190 allograft recipients. The detection of CMV-IE antigens and CMV-IE DNA in PBMNC indicates that positive cells may represent truly infected cells. The relation between increased cytokine plasma levels (particularly following treatment by pan-T cell antibodies) and the appearance of CMV antigens in PBMNC suggests that cytokines may play an important role in the reversal of CMV latency. This hypothesis is supported by our finding that tumor necrosis factor-alpha (TNF) is able to stimulate the activity of the CMV-IE enhancer/promoter region in the human monocytic cell line, HL-60. The interleukins 1, 2, 3, 4, 6, 8 and 10; transforming growth factor-beta; interferongamma; and granulocyte/macrophage colony-stimulating factor did not show any enhancing effect on the CMV promoter activity. Thus, TNF-alpha seems to play a key role in regulating the balance between latency and reactivation of CMV infection. Inhibition of TNF-alpha release or action may be an alternative strategy for preventing CMV-associated morbidity in allograft recipients.

Interruption of the radial nerve at proximal level: reconstruction following anterior transposition

The authors describe two cases of radial paralysis due to interruption in the proximal level, treated by autologous nerve grafting, following anterior transposition. At long-term follow-up, in one case after 12 years, there was good functional recovery, while in the second case there was still no recovery after 2 years. The surgical technique involving anterior transposition of the nerve is described, which in this type of lesion facilitates neurorrhaphy.

[Animal model for the study of the anhepatic state]

Hepatectomy in the pig is impossible without simultaneous removal of intrahepatic caval vein. The authors covered the vascular gap using a siliconized glass prosthesis, completed with rubber tubes. 16 animals were operated upon in this manner and survived between 6 and 34 hours. In only two cases thrombi were found in the prosthesis.

Post-traumatic acute subdural haematoma of the posterior fossa extending toward the cerebello-pontine region. Report of a case

The case of a 73 year old lady hit by a truck is presented. The patient after a short lucid interval (2 hours) became deeply comatose. CT scan (performed in the clinical phase of minor head injury) showed a posterior fossa subdural haematoma (PFSH) extending towards the cerebello-pontine angle and the brainstem. Prompt evacuation of the haematoma led to recovery with severe disability. Mechanisms and causes of acute PFSH are discussed. As in other published cases the clinical diagnosis of a PSFH is difficult; mortality and morbidity are extremely high in spite of surgical treatment.

Endoscopic approach to cubital tunnel syndrome

The cubital tunnel syndrome is one of the most common entrapment neuropathy of the upper limb. The ulnar nerve can be compressed in the oteofibrous tunnel by the bone structures, the Osborne's ligament, the fascia of the ulnar flexor muscle of the carpus or of the aponeurosis of the deep flexor of the fingers. Pressure values in the cubital tunnel >50 mm Hg induce blocking of intraneural circulation with electrodiagnostic modifications, clinical signs and histological changes including demyelinazion of the nerve proximal to the cubital tunnel. Surgery becomes essential in case of failure of conservative and physical therapy. Various surgical techniques have been described in the literature for the treatment of the ulnar neuropathy at the elbow. In this paper the authors report a new endoscopic technique for the treatment of ulnar nerve entrapment at the elbow which requires respect of specific electrodiagnostic and clinical criteria of inclusion. The restored joint active motion following elbow arthroscopy in osteoarthritis can induce or get worse a ulnar nerve neuropathy; endoscopy neurolysis is essential to remove perineural adherences and reduces the nerve stress. Immediate well-being of the patient, lesser invasiveness and minimum vascular complications are clear advantages of the endoscopic approach, while the treatment of the pathologies proximal and distal to the Struther's arcade is a limit of the technique.