Cases reported "Craniocerebral Trauma"

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1/96. Post-traumatic pituitary apoplexy--two case reports.

    A 60-year-old female and a 66-year-old male presented with post-traumatic pituitary apoplexy associated with clinically asymptomatic pituitary macroadenoma manifesting as severe visual disturbance that had not developed immediately after the head injury. skull radiography showed a unilateral linear occipital fracture. magnetic resonance imaging revealed pituitary tumor with dumbbell-shaped suprasellar extension and fresh intratumoral hemorrhage. Transsphenoidal surgery was performed in the first patient, and the visual disturbance subsided. decompressive craniectomy was performed in the second patient to treat brain contusion and part of the tumor was removed to decompress the optic nerves. The mechanism of post-traumatic pituitary apoplexy may occur as follows. The intrasellar part of the tumor is fixed by the bony structure forming the sella, and the suprasellar part is free to move, so a rotational force acting on the occipital region on one side will create a shearing strain between the intra- and suprasellar part of the tumor, resulting in pituitary apoplexy. Recovery of visual function, no matter how severely impaired, can be expected if an emergency operation is performed to decompress the optic nerves. Transsphenoidal surgery is the most advantageous procedure, as even partial removal of the tumor may be adequate to decompress the optic nerves in the acute stage. Staged transsphenoidal surgery is indicated to achieve total removal later.
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2/96. Reconstruction of a cranial bone defect with hydroxyapatite and free flap transfer.

    The authors report a successful reconstruction of an extensive frontotemporal bone defect after craniotomy, which was complicated with infection and necessitated removal of frontal and temporal bones. The large frontotemporal bone defect was reconstructed using prefabricated hydroxyapatite blocks in combination with the free vastus lateralis muscle flap. The patient's functional and cosmetic restoration has been maintained for 10 months' follow-up.
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3/96. An arachnoid cyst involving only the hypoglossal nerve: case report and review of the literature.

    We describe a patient with an arachnoid cyst, possibly of traumatic origin, at the hypoglossal canal producing atrophy of the tongue. An arachnoid cyst should be considered in the differential diagnosis of any patient with a localized cystic mass around the cranial nerves at the base of the skull.
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4/96. Unusual occipital condyle fracture with multiple nerve palsies and Wallenberg syndrome.

    A 52-year-old male presented with an extremely rare fracture of the occipital condyle involving the jugular foramen with marked medial rostrad displacement of the fragments. He had ipsilateral VII through XII nerves palsies and Wallenberg syndrome. Conservative treatment did not improve the cranial nerve palsies. A high-resolution CT-scan is essential to visualize these fractures.
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5/96. Mild head injury with isolated third nerve palsy.

    Traumatic isolated cranial nerve palsies are uncommon and when they do occur, they are usually associated with severe head trauma. Cranial nerve palsy associated with mild head injury is rare. A case is reported of complete left third nerve palsy associated with mild head injury. The rate of recovery for complete third nerve palsy is slow and prolonged. The ptosis recovered in 10 months; the divergent squint required botulinum toxin to the lateral rectus muscle followed by surgery.
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6/96. The injured coach.

    The patient in this case was diagnosed as having an epidural hematoma (shown in x-ray at right). This results from hemorrhage between the dura mater and the skull. The hemorrhage may result from a traumatic insult to the side of the head, which can fracture the temporal bone and lacerate the middle meningeal artery. Since the hemorrhage is arterial in nature, the patient may deteriorate quickly. These patients may present with what is referred to as a "lucid interval." The patient typically has a significant blow to the head that results in a short period of unconsciousness. They then regain consciousness at a time that frequently coincides with the arrival of EMS. Once conscious, they are in a period known as the lucid interval. They will still have a headache, but may otherwise be acting normally and show no other physical findings on examination. Many such patients refuse treatment and transport. [table: see text] Inside the skull, however, the problem will grow. Broken arterial vessels are bleeding, causing an expanding hematoma. The patient typically will soon complain of a severe headache along with other associated complaints, such as nausea/vomiting, then will lose consciousness again and/or have a seizure. Initial physical findings may include contralateral weakness and a decreased Glasgow coma score. As the hematoma expands, cerebral herniation may occur, compressing the third cranial nerve, which presents as a "blown pupil." EMS providers should have a high suspicion of injuries that affect the side of the head and the base of the skull. It is important to not only assess such injuries, but also the mechanism of injury, and to know the complications or later presentation that can arise from such injuries. Given that this patient was alert, oriented, not obviously intoxicated, and accompanied by his wife, the providers in this case would have had no choice but to abide by a refusal of treatment and transport. However, that could lead to serious complications, such as ongoing minor neurological deficits, later on. If this is the case, contacting medical control should be the priority.
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7/96. evoked potentials in acute head injured patients with MRI-detected intracerebral lesions.

    BACKGROUND: magnetic resonance imaging (MRI) allows precise detection of intracranial lesions in head injured patients. We compared intracranial lesions detected in MRI to somatosensory evoked potentials (SEP) and brainstem auditory evoked potentials (BAEP) concerning their prognostic value. methods: Thirty patients with traumatic brain injury and prolonged recovery were studied. Size, side and number of 474 intra- and extraparenchymal lesions as well as lesion localisation based on a specific anatomical classification were entered into a database (a total of 7080 data). In addition, we recorded median-nerve SEP (M-SEP), tibial nerve SEP (T-SEP) and BAEP in all of the patients. FINDINGS: M-SEP and Glasgow-Outcome-Score (GOS) one year after injury correlated significantly to patients with lesions in the brainstem (p<0.0001) and corpus callosum (p<0.001). Similar results were found for T-SEP (p<0.0001). All patients with bicortical loss of M-SEP had an unfavourable outcome (GOS 2). Among the analysis of lesion volume, only the volume of brainstem lesions correlated to GOS (p<0.001), but this was not found for callosal lesions. However, comparing the vegetative (GOS 2) to the non-vegetative group (GOS 3-5), for both callosal (p<0.02) and brainstem (p<0.005) lesions a significant correlation was found. INTERPRETATION: MRI does not improve the prognostic reliability of SEP in head injury but offers possibilities for clarifying electrophysiological and clinical pathologies. This explains that the volume of brainstem lesions, essentially influencing the clinical outcome, is strongly correlated to T-SEP and M-SEP. In contrast, callosal lesions did not show a clear relationship to outcome despite large callosal lesions (>4 ml) which tended to poor outcome. In conclusion, we suggest that MRI and SEP are supplementary to each other concerning prognostic evaluation.
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8/96. dissection of the intracranial internal carotid artery producing isolated oculomotor nerve palsy with sparing of pupil.

    dissection of the internal carotid artery usually occurs in the cervical segment, but rarely may involve the artery in the intracranial course (1). The clinical course of intracranial dissection is often catastrophic, with rapid onset of profound neurological deficit, as a result of middle and/or anterior cerebral artery involvement. When this occurs the mortality rate is generally considered high. We describe a case of intracranial internal carotid artery dissection following trivial trauma presented with an isolated painful pupillary sparing oculomotor nerve palsy.
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9/96. Severe papilledema identified 3 weeks after head injury.

    A 62-year-old woman presented with rapidly developed visual disturbance without associated headache or nausea 3 weeks after head injury. Ophthalmologic examination revealed bilateral severe papilledema with retinal hemorrhage, and intracranial pressure (ICP) was 17.5 cmH2O estimated by lumbar puncture. Computed tomography and magnetic resonance (MR) imaging showed no evidence of increased ICP, except dilation of the subarachnoid space around the optic nerves with distortion of the nerves. Her visual acuity remarkably improved after steroid and glycerol treatment, and optic fundus examination revealed bilateral clear optic papillae without atrophic changes. Follow-up MR imaging demonstrated that the bilateral optic nerves had regained the normal appearance. These results indicate that the bilateral papilledema was caused by increased subarachnoid pressure around the bilateral optic nerves. We conclude that papilledema can occur with a mildly increased ICP and trapped subarachnoid cerebrospinal fluid around the optic nerves, and papilledema may progress after the ICP is normalized. papilledema is a warning sign for increased ICP, associated with future visual loss from retinal hemorrhage. Therefore, repeated funduscopic investigation is necessary for the early diagnosis and treatment of papilledema.
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10/96. Managing head injuries.

    The patient who presents with a serious head injury is often very difficult to manage. The airways is of primary concern; adequate ventilation must be provided and aspiration protected against. Recent studies suggest that hyperventilation may be as beneficial as was earlier believed. As the pCO2 level decreases, vasoconstriction occurs. If the level falls too low, cerebral perfusion is restricted, and profound cerebral anoxia may ensue. Current standards call for a ventilatory rate to allow for moderate respiratory alkalosis, in theory to mildly constrict teh vessels but still provide adequate perfusion. Arterial blood gas analysis in the ED is the definitive measurement of airway management in the field. Remember that the anatomy of the meningeal layers places the arteries primarily in the epidural space and the veins in the subdural space. A bleed in the epidural space often presents with a rapid onset of signs and symptoms, as was obvious in this traumatized patient. When a bleed occurs in the subdural space, the onset is usually more insidious, and an accurate history is a key to field diagnosis. As the hemorrhage expands, compression displaces the brain within the cranial vault. This displacement causes pressure to be exerted on the medulla of the brainstem. Cushing's Traid is a result of this pressure on the medulla and is evidence by the pulse slowing while systolic blood pressure rises and respirations become ataxic. vomiting is often associated, and as the bleed continues, herniation syndrome begins. Decorticate posturing is displayed, followed by decerebrate posturing if relief is not provided. It is important to distinguish between decorticate and decerebrate posturing. It is important to distinguish between decorticate and decerebrate posturing. An easy way to remember the differences is to picture the anatomy of the brain. The cerebral cortex lies above the cerebellum, so when a patient's arms flexed up toward the face , he is pointing to his "core" (de-cor-ticate). As the arms extend downward, he is pointing to his cerebellum(de-cere-brate). T o manage the head-injured patient, it is imperative to anticipate potential developments, as well as protect against underlying injuries that may not be fully evaluated until arrival at the ED. Cervical spine often accompany head injuries, and full spinal immobilization is a mandatory precaution in all presentations. With the expanding hematoma found on this patient's neck, vascular damage ws obvious and contributed to the suspicion of spinal injury. As the intracranial pressure rise, vomiting and seizures are common. Placement of an endotracheal tube and having suction equipment ready are the best tools to prevent against aspiration. It is possible to angle the long spine board 10-15 degrees, exercising caution to ensure the patient's spinal alignment is not manipulated during the process. seizures are usually treated with anticonvulsants like Valium. When a seizure accompanies a head injury, it is a direct result of the increased intracranial pressure and has a generally poor response to Valium, as the underlying cause of the seizure still exists. In this case, the patient had a full neuromuscular blockade, and any seizure would not have been recognized as long as the paralytics were on board. Early notification to the ED is essential, reporting all findings and interventions. This can alert them and give them the opportunity to prepare specialized equipment, such as CT scanners, mechanical ventilators, etc. Also, consider transportation options and the length of time to definitive care, including neurosurgical evaluation. This patient needs to be seen in a trauma center capable of the most thorough evaluation and management. Evacuation by air ambulance may be the most appropriate method of transport.
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