11/18. Medicolegal diagnostic value and clinical significance of traumatic incomplete tears of the basilar artery. Ruptures of arteries of the vertebrobasilary system are relatively frequent in medicolegal practice, and their origin may be both natural and violent. tears that affects the whole thickness of the basilar artery cause subarachnoid hemorrhage (SAH), with an often rapid fatal outcome. 1-3 However, in some situations, arterial tears may be incomplete, involving the intima or both the intima and the media, but with preserved adventitia. 1, 4 Although such incomplete tears are not the source of immediate subarachnoid bleeding, their presence may be important from both a medicolegal and a clinical point of view.The aim of this article is to point out the significance of incomplete tears of basilar artery as a possible diagnostic sign of traumatic origin of SAH as well as a certain mechanism of injury, which involves forcible hyperextension and rotational movements of the head. The authors also describe their method of performing longitudinal section of the basilar artery, both at autopsy and for histologic examination, which is convenient for identifying multiple transversal incomplete tears of this blood vessel. The article is based on the analysis of three cases from the autopsy material of the Institute of forensic medicine in Belgrade. ( info) |
12/18. Hyperextension and rotation of head causing internal carotid artery laceration with basilar subarachnoid hematoma. Hyperextension of the head can cause injury to the vessels at the base of the brain. These lacerations are believed to be caused by stretching of the vessels due to the abrupt movement of the head and rotational acceleration of the brain within the cranium, and they usually occur in the intracranial portions of the vessels, producing a subarachnoid hemorrhage. This is the case of a 35-year-old man who received a blow to the face that forcefully hyperextended and rotated his head to the left. autopsy revealed an intracranial right internal carotid laceration extending from a calcified atherosclerotic plaque. This unusual injury may be due to a combination of blunt force applied to the head and the alteration of the vessel's structural and functional capacities secondary to atherosclerosis. ( info) |
13/18. Delayed hydrocephalus as an unusual complication of a stab injury to the spine. STUDY DESIGN: Case report. OBJECTIVE: To report a rare complication following a stab injury to the upper cervical spine and cord. SETTING: National spinal injury unit in a Scottish university teaching hospital. CASE REPORT: A 19-year-old male sustained a stab injury to his upper cervical spine, with a partial cord transection. After 5 months of rehabilitation, his condition deteriorated. CT scans showed hydrocephalus, which was treated by shunting. After shunting, the patient's condition improved but he remained tetraplegic requiring ventilatory support at night. CONCLUSION: hydrocephalus as a late complication of a cervical spine injury is rare but should be considered if the condition of the patient with an upper cervical spine injury deteriorates. The likely mechanism of the hydrocephalus development is also discussed. ( info) |
14/18. Successful resection of a left insular cavernous angioma using neuronavigation and intraoperative language mapping. Despite recent literature advocating the surgical removal of symptomatic Cavernous Angiomas (CA), even in critical brain areas, very few observations of insular CA surgery have been described, particularly in the left hemisphere. We report the case of a successful resection of a CA located in the dominant insula, using both neuronavigation and intra-operative functional mapping. This 33-year-old right-handed man harbored a left insular CA, revealed by generalized seizures following a bleed confirmed on MRI. The preoperative examination was normal. A stereotactic-guided surgery was performed under local anesthesia, with intra-operative functional mapping using direct cortico-subcortical electrical stimulation in the awake patient--allowing the surgeon to achieve total resection of both CA and pericavernomatous gliosis, as shown on repeated postoperative MRIs. There was no postsurgical deficit, nor any seizure without treatment (follow-up: 4.5 years). The diagnosis of CA was confirmed by histological examination. Taking account of the risk of morbidity due to the natural history of CA, particularly in eloquent brain regions, we suggest to routinely consider the possibility of a surgical treatment in cases of symptomatic (left dominant) insular CA, using combined intra-operative anatomical and physiological localization methods. ( info) |
| BACKGROUND: Recombinant activated factor VII (rFVIIa) is being tested to improve hemostasis in a variety of bleeding disorders. Clinical indications and efficacy are still being evaluated for this product. CASE REPORT: Over a 17-month period, rFVIIa was used to treat central nervous system hemorrhage in three patients who were found to have isolated FVII deficiency (21%, 40%, 27%). Patient A fell 30 feet, Patient B suffered a motor vehicle accident, and Patient C had a spinal cord hematoma. None of the patients had a history of bleeding diathesis. All three patients received rFVIIa after failing initial treatment with fresh-frozen plasma. RESULTS: Patient A was treated with 11 doses (initial dose 95 microg/kg; subsequent doses 8-38 microg/kg) over 10 days; Patient B received 13 doses (45-60 microg/kg) over 13 days; and Patient C received 5 doses (12-24 microg/kg) over 4 days. The prothrombin time corrected from 16.2 /- 1.8 (mean /- SD) to 11.2 /- 1.6 seconds after infusion of rFVIIa, but returned to pretreatment level in 14 /- 4 hours. At the cessation of therapy, all patients showed neurologic improvement. No complications related to the infusion of rFVIIa occurred. CONCLUSION: The use of rFVIIa may be of value both for its general effect on hemostasis, and specifically in the setting where there is a documented reduction in FVII. Doses lower than those used in patients with FVIII inhibitors appear to be effective in the setting of central nervous system hemorrhage. ( info) |
16/18. Superficial siderosis of the central nervous system following cervical nerve root avulsion: the importance of early diagnosis and surgery. Superficial siderosis (SS) of the central nervous system is an insidious, progressive, irreversible and debilitating neurological disorder caused by recurrent haemorrhage within the subarachnoid space. The subsequent deposition of haemorrhagic breakdown products in the spinal cord and nervous tissues leads to the loss of neurones and myelin, and to the development of a neurological deficit. In a small number of patients, the source of haemorrhage is related to traumatic cervical nerve root avulsion occurring several years prior to the onset of symptoms. Surgical ablation of the source has been shown to halt the progression of the disease, at least in the short term. We review the literature on SS secondary to cervical nerve root avulsion and report a further case in which surgical management was successful in halting disease progression. We emphasize that early detection and recognition of the initial non-progressive symptoms related to this poorly known disease, coupled with timely surgical management, minimizes the degree of neurological disability. ( info) |
17/18. Anomalous internal carotid anastomosis to contralateral anterior cerebral artery. BACKGROUND: Many anomalies and variants in vascular anatomy have been reported in relation to the anterior cerebral artery (ACA). patients AND methods: We encountered an apparently novel anomaly in a 30-year-old man admitted for disturbance of consciousness following a traffic accident. Computed tomography revealed an acute subdural hematoma and subarachnoid hemorrhage. RESULTS AND CONCLUSIONS: No vascular abnormalities related to the hemorrhage were detected by conventional angiography, so we concluded that the bleeding was of traumatic origin. Anomalous origin of the ACA was disclosed incidentally, with both A1 segments arising from the right internal carotid artery; no normal A1 segment of the left ACA was visualized. We discuss possible bases for this anomalous origin. ( info) |
18/18. Early combined cranioplasty and programmable shunt in patients with skull bone defects and CSF-circulation disorders. OBJECTIVE: This study assesses the clinical outcome after early combined cranioplasty (own frozen bone) and shunt implantation (Codman-Medos programmable VP shunt) in patients with skull bone defects and cerebrospinal fluid (CSF) circulation disorders.METHOD: medical records were reviewed retrospectively for the last 100 patients with CSF disorders after trauma or subarachnoid hemorrhage (SAH), who previously underwent decompressive craniotomy owing to therapy-resistant brain swelling. patients treated with early (5 to 7 weeks after injury) combined cranioplasty and shunt implantation were analysed and a follow-up for the survivors was obtained.RESULTS: In 60 patients with a daily CSF external drainage over 150 ml and dilated ventricles in CT scan, a programmable VP shunt was implanted simultaneously with the cranioplasty within 5.1 weeks after decompression. The neurological condition 6 months later was good (independent patients) in 39 cases (65%); 12 patients (20%) survived with a severe disability; three patients (5%) remained in a persistent vegetative state and only six patients (10%) died. There were few complications: bone or shunt infection (three cases), post-operative intracranial bleeding (one case), transitory neurological impairment after bone reimplantation (two cases), bone resorption (two cases) and shunt dysfunction (three cases).CONCLUSION: The early reimplantation of the patient's own skull bone combined to the employment of a programmable shunt system allowed us a dynamic adjustment of the intracranial pressure (ICP) changes. The combined treatment reduced the number of required surgical procedures, complications and unsatisfactory patient outcomes. ( info) |