Spinal epidural hematoma caused by extradural arteriovenous malformation: a case report and review of the literature.

About 330 cases of spinal epidural hematoma have been reported in the literature but few cases had pathologically proven extradural arteriovenous malformation. The authors report a case of spinal epidural hematoma caused by extradural arteriovenous malformation. The patient presented with a sudden onset of back pain followed by rapidly progressive neurological deficit. MRI was the procedure of choice for diagnosis of this lesion. Treatment was emergency surgical decompression. Prognosis depends on the preoperative neurological deficit, operative interval and localization of the hematoma.

Intraoperative intracranial aneurysm rupture.

119 patients with surgically treated intracranial aneurysm between December 18, 1984 and October 1997 were analyzed resulting in nine patients with intraoperative aneurysm rupture. These nine cases formed the basis of this study. The incidence of intraoperative aneurysm rupture was 7.6 per cent. The mortality was 33.3 per cent. In our institution, maneuvers used to control profuse hemorrhage include induced hypotension, suction dissection, and temporary clips at the parent vessels. Some controversies exist regarding the effect of timing of surgery on intraoperative aneurysm rupture and ischemic consequence from induced hypotension. The argument is whether early surgery, within 72 hours, increases the incidence of intraoperative aneurysm rupture.

Post-traumatic hydrocephalus: experience in 17 consecutive cases.

BACKGROUND: Ventriculomegaly after head injury is one of controversial debate. Currently there is no definite way to distinguish post-traumatic hydrocephalus (PTH) from cerebral atrophy. The favourable outcome is only from CSF shunting in patients with true post-traumatic hydrocephalus, not hydrocephalus exvacuo. METHOD: 17 patients with post-traumatic hydrocephalus were retrospectively reviewed from January 1993 to February 1996 to determine risk factors and guidelines for the management of this problem. RESULTS: These 17 patients represented 1.6 per cent of the 1080 head-injured patients seen at Songklanagarind Hospital during that period. 385 patients were classified as severe head injury in whom 7 were complicated with post-traumatic hydrocephalus. Our study found a high incidence of correlation between PTH and decompressive craniectomy. The late effect of decompressive craniectomy may cause CSF blockage around the convexities and hydrocephalus. The diagnoses were based on clinical manifestations and CT scan appearances. The outcome was related closely to the initial GCS score and the method used for diagnosis. CONCLUSION: Post-traumatic hydrocephalus was 1.8 per cent in patients with severe head injury. Late neurological deterioration confirmed by CT scan findings was more useful than CT scan findings alone. CSF shunting was effective in patients with ventriculomegaly who had clinical signs and symptoms of increased intracranial pressure from post-traumatic hydrocephalus.

Endoscopic third ventriculostomy.

We prospectively studied 8 patients who had an endoscopic third ventriculostomy performed between 1996 and 1997 in Songkhlanagarind Hospital. The surgical technique was described. Seven operations were successful and one operation failed. Success was found in cases of pure aqueductal stenosis, aqueductal stenosis with Dandy Walker malformation, and posterior fossa tumor. In a patient where an endoscopic third ventriculostomy failed, aqueductal stenosis with marked hydrocephalus was found. Marked dilation of the third ventricle could compress the aqueduct of Sylvius. Although there was communicating hydrocephalus, it looked like non-communicating hydrocephalus. To avoid a valvular shunting complication, we suggest performance of an endoscopic third ventriculostomy in selected non-communicating hydrocephalus patients.

Traumatic hematomas of the posterior cranial fossa.

The objective of this study was to find out the result of treatment and the factors which can predict the outcome of traumatic hematomas of the posterior cranial fossa. Twenty two patients with traumatic hematomas of the posterior cranial fossa from 1,500 patients with traumatic intracranial hematomas were analyzed. There were fourteen male and eight female patients. The most common etiology was a motor vehicle accident. About 90 per cent of the patients had a direct injury to the occipital region. Ninety per cent of the patients had an occipital skull fracture or diastatic fracture of the lambdoid suture. The overall mortality rate was about 38 per cent. Patients having pure epidural hematoma had zero mortality. By contrast, patients suffering epidural hematoma with associated intracranial hematoma had 20 per cent mortality. Intracerebellar hematoma led to 60 per cent mortality. Glasgow Coma Scale (GCS) before operation was used to predict the patients' outcome. Ninety per cent of the patients who had a GCS between 13 and 15 had a good recovery. By contrast, only 30 per cent of the patients who had a GCS below 9 had a good recovery. Statistical analysis showed that the GCS value of below 9 predicted the poor outcome for the patients.

The further surgical experiences in intracranial meningiomas at Songklanagarind Hospital.

Meningioma is a common benign intracranial tumor documented in many reports. We retrospectively reviewed 81 patients with a total of 84 meningiomas. There were 61 females and 20 males. Most patients were in the third to sixth decades of life. The most common presenting symptoms were headache and decreased visual acuity. Focal neurological deficits and signs of increased intracranial pressure were found in most patients. The three most common tumor locations were falx and parasagittal, sphenoid wing and convexity. Of the 84 meningiomas, 67 were completely resected and 17 were partially resected. Operative morbidities were accounted for by hemiparesis, cranial nerve palsy and infection. There was only one operative death in our series. 70 patients had normal and good results, 4 patients had severe disabilities and results were unknown in 6 patients. Recurrences were detected in 8 patients and 5 patients underwent surgery again with good results in 4 patients. Recurrences occurred in 3 patients with total and 5 patients with subtotal resections. The most significant factor for recurrence was the extent of tumor resection.