1/18. Successful closure of recurrent traumatic csf rhinorrhea using the free rectus abdominis muscle flap.BACKGROUND: We present two patients in whom a free rectus abdominis muscle flap was used to close recurrent traumatic CSF rhinorrhea. CASE DESCRIPTION: CT scan of both patients showed frontal lobe atrophy and porencephaly after contusional hematoma. In the first patient, because the site of CSF leakage was not identified and the patient underwent three unsuccessful attempts to close the fistula using the fascia lata, we treated the patient by unifying all paranasal sinuses and by filling them with a free rectus abdominis muscle flap. In the second patient, CSF rhinorrhea recurred 6 years after closure of the fistula using the fascia lata. The patient underwent separation of a porencephalic cyst from the paranasal sinus and a free muscle flap was placed extradurally, because the CSF pulse pressure in the enlarged left anterior horn eroded the previously repaired fascia lata, resulting in the recurrence of CSF leakage. CONCLUSION: Although duraplasty is the primary procedure for repairing dural fistulas, the vascularized free muscle flap is an alternative method when the location of the fistula is not identified or the patient with recurrent CSF rhinorrhea has severe frontal lobe atrophy and porencephaly.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
2/18. Progressive hemorrhage after head trauma: predictors and consequences of the evolving injury.OBJECT: Progressive intracranial hemorrhage after head injury is often observed on serial computerized tomography (CT) scans but its significance is uncertain. In this study, patients in whom two CT scans were obtained within 24 hours of injury were analyzed to determine the incidence, risk factors, and clinical significance of progressive hemorrhagic injury (PHI). methods: The diagnosis of PHI was determined by comparing the first and second CT scans and was categorized as epidural hematoma (EDH), subdural hematoma (SDH), intraparenchymal contusion or hematoma (IPCH), or subarachnoid hemorrhage (SAH). Potential risk factors, the daily mean intracranial pressure (ICP), and cerebral perfusion pressure were analyzed. In a cohort of 142 patients (mean age 34 /- 14 years; median glasgow coma scale score of 8, range 3-15; male/female ratio 4.3: 1), the mean time from injury to first CT scan was 2 /- 1.6 hours and between first and second CT scans was 6.9 /- 3.6 hours. A PHI was found in 42.3% of patients overall and in 48.6% of patients who underwent scanning within 2 hours of injury. Of the 60 patients with PHI, 87% underwent their first CT scan within 2 hours of injury and in only one with PHI was the first CT scan obtained more than 6 hours postinjury. The likelihood of PHI for a given lesion was 51% for IPCH, 22% for EDH, 17% for SAH, and 11% for SDH. Of the 46 patients who underwent craniotomy for hematoma evacuation, 24% did so after the second CT scan because of findings of PHI. Logistic regression was used to identify male sex (p = 0.01), older age (p = 0.01), time from injury to first CT scan (p = 0.02), and initial partial thromboplastin time (PTT) (p = 0.02) as the best predictors of PHI. The percentage of patients with mean daily ICP greater than 20 mm Hg was higher in those with PHI compared with those without PHI. The 6-month postinjury outcome was similar in the two patient groups. CONCLUSIONS: Early progressive hemorrhage occurs in almost 50% of head-injured patients who undergo CT scanning within 2 hours of injury, it occurs most frequently in cerebral contusions, and it is associated with ICP elevations. Male sex, older age, time from injury to first CT scan, and PTT appear to be key determinants of PHI. Early repeated CT scanning is indicated in patients with nonsurgically treated hemorrhage revealed on the first CT scan.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
3/18. Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature.Migration of distal ventriculoperitoneal shunt tubing is known to occur in a wide of variety of locations. The authors report an unusual complication involving a previously confirmed intraperitoneal shunt catheter that migrated into the heart and pulmonary vasculature. Radiographic evidence suggested that this occurred secondary to cannulation of a segment of the external jugular vein with a shunt trochar during tunneling of the distal catheter. This is the sixth reported case of a peritoneal shunt tube migrating proximally into the heart. The authors review the literature regarding migration of distal tubing into the heart and pulmonary artery. Based on imaging studies obtained in the present case, the authors posit that the mechanism for this unusual type of shunt migration is inadvertent penetration of either the internal or external jugular vein during the initial tunneling procedure. Negative intrathoracic pressure and slow venous flow then draws the catheter out of the peritoneum and into the vasculature. The distal catheter then migrates into the right side of the heart and pulmonary artery. diagnosis and management of this type of complication is discussed.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
4/18. Late brain abscess years after severe cerebrocranial trauma with fronto-orbitobasal fracture.An 8-year-old boy suffered severe craniocerebral trauma with left-sided fronto-orbitobasal fracture. The CT scan showed minor subdural air inclusions. The child recovered well and had no clinical signs of aftereffects. Eight years after the accident, symptoms of intracranial pressure developed progressively with nuchal rigidity and elevated temperature. The CT showed an extensive left fronto-orbitobasal abscess. The intraoperative finding was a brain prolapse both into the frontal sinus and into the ethmoidal cavity with a large dura-bone defect at the site of the former fracture line, which was closed with refobacin-bone-meal fibrin sealant plasty and glued periostal patch. The postoperative course was unremarkable. Evidently, the accident had caused a brain prolapse into the bone defect, which prevented liquorrhea. Due to the lack of bone and dura barrier, a late brain abscess developed in the course of sinusitis. In such cases, primary surgical revision seems to be indicated.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
5/18. Mechanisms of hyperventilation in head injury: case report and review.We report the case of a head-injured patient with spontaneous hyperventilation who had recurrent episodes of relative hypoventilation associated with increases in intracranial pressure. Detailed ventilatory studies were performed during the 2nd week after injury. Our findings in this patient prompted us to review the possible mechanisms underlying the observed changes. We suggest that spontaneous hyperventilation in head injury is secondary to a decrease in cortical inhibitory influences on respiratory control mechanisms and that the transient episodes of relative hypoventilation observed in our patient may reflect modified ventilatory responses dependent on the altered state of consciousness. (neurosurgery, 5: 701--707, 1979).- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
6/18. Neurological manifestations in abused children who have been shaken.Four infants with the 'shaken infant syndrome' are described. None had skull fractures and only one had a subdural hematoma. All had extensive retinal and pre-retinal hemorrhages. Follow-up computerized tomography showed severe brain atrophy, multiple hypodense areas and ventricular enlargement. Three of the patients suffered severe, permanent brain damage, with mental retardation, spasticity and blindness. It is suggested that the underlying pathogenesis of this syndrome is acutely increased intrathoracic pressure, transmitted into the head to cause multiple venous infarctions. Retinal and pre-retinal hemorrhages are cardinal features of this syndrome and their presence should raise the suspicion of this form of battering in the absence of the 'classical' signs of battering.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
7/18. heart-rate variability in brain-damaged adults.To test whether or not the characteristics of the adult heart-rate reflect the condition of the central nervous system (as they seem to do in the fetus), ten patients with neurological deficits of acute onset were studied. No patients had received drugs and none was hypoxic. The findings indicate that the normal cyclic changes in heart-rate are reduced in the presence of severe brain damage. Variability decreases rapidly if intracranial pressure rises, and the rate of return of variability reflects the subsequent state of neuronal function, even when intracranial pressure has been restored to normal. In this limited setting, then, it appears that heart-rate variability may reflect the functional state of the central nervous system.- - - - - - - - - - ranking = 2keywords = pressure (Clic here for more details about this article) |
8/18. Rapid enlargement of ventricles within seven hours after head injury.We report a case of acute enlargement of the ventricles within 7 hours after head injury that was documented by repeated computerized tomography. It is suggested that the pathophysiological mechanism for this rapid enlargement of ventricles may be due to the raised intracranial pressure (ICP) that results from obstruction of cerebrospinal fluid pathways by subarachnoid hemorrhage, in addition to the elevation of ICP aggravated by frequent focal convulsive seizures.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
9/18. Unilateral morbus Purtscher with poor visual outcome.Two cases are presented, one with a pure cranial compression injury, the other mainly with chest trauma. Both patients noted immediate unilateral blindness. Vision did not improve in either within four months. fluorescein angiography was performed and showed arteriolar as well as venous damage, with occlusion of arterioles and venules. As the impact in morbus Purtscher is usually very brief, reflux cannot explain the fundus changes. More likely a pressure wave is the cause of vessel damage with subsequent infiltration of blood, or plasma, into the wall of the vessel and obliteration of the lumen; it is also a cause of rupture of capillaries and hemorrhage. In traumatic asphyxia, on the contrary, a sustained force leads to reflux of blood and massive congestion with subsequent vessel damage and diapedesis. The prognosis in morbus Purtscher is often poor.- - - - - - - - - - ranking = 1keywords = pressure (Clic here for more details about this article) |
10/18. Effect of the valsalva maneuver on intracranial hypertension.We describe a case of intracranial hypertension in a previously healthy 25-year-old man who sustained a head injury in a motor vehicle accident, in whom a valsalva maneuver resulted in parallel reductions in mean arterial blood pressure, cerebral blood flow velocity in the middle cerebral artery, and intracranial pressure. The effects of raising intrathoracic pressure in patients with intracranial hypertension are discussed.- - - - - - - - - - ranking = 3keywords = pressure (Clic here for more details about this article) |
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