A makeshift blue light filter for endoscopic identification of traumatic cerebrospinal fluid leak using fluorescein

Objective@#To describe a makeshift blue light filter for endoscopic visualization of a traumatic cerebrospinal fluid leak repair using intrathecal fluorescein and its application in one patient.@*Methods@# Study Design:Surgical Instrumentation Setting:Tertiary Government Training Hospital Patient:One @*Results@#Intra-operative endoscopic identification of fistulae sites was achieved using intrathecal injection of fluorescein that fluoresced using our makeshift blue light filter in a 43-year-old man who presented with a 3-month history of rhinorrhea due to skull base fractures along with multiple facial and upper extremity fractures he sustained after a fall from a standing height of 6 feet. He underwent transnasal endoscopic repair of cerebrospinal fluid fistulae in the planum sphenoidale, clivus and sellar floor. Post-operatively, there was complete resolution of rhinorrhea with no complications noted. @*Conclusion@#Our makeshift blue light filter made from readily available materials may be useful for endoscopic identification of CSF leaks using fluorescein in a low- to middle-income country setting like ours.

Cesárea electiva en gestante con fractura-hundimiento antigua en región frontal del cráneo / Pregnant With an Old Fracture-Sink in Skull Frontal Region Determines Elective Caesarean Section

Los traumatismos craneoencefálicos constituyen una epidemia silenciosa para la Organización Mundial de la Salud; y en específico, las fracturas de cráneo tienen una incidencia elevada en la sociedad moderna. El objetivo es presentar el caso de una embarazada con una fractura craneal antigua (fractura-hundimiento frontal) que condiciona la indicación de una cesárea electiva. Además, resulta una afectación anatómica poco habitual en la práctica de la Obstetricia. Se presenta una gestante de 22 años que a la edad de 4 años sufrió trauma craneoencefálico al caer accidentalmente desde un cuarto piso. Se impactó en la región frontal del cráneo con un recipiente de cerámica pesado. Quedó inconsciente y con sangrado profuso, se operó de urgencia y la paciente quedó sin secuela clínica de daño cerebral, pero con deformidad craneal por hundimiento de forma ovalada bien delimitada. Se determinó cesárea electiva por orientación del Programa Materno Infantil Nacional a las 40,5 semanas, peso del recién nacido 3 802 g y Apgar 9-9. Tuvo una evolución satisfactoria durante su atención prenatal y puerperio. La valoración y el manejo de una gestante con antecedentes de un traumatismo craneoencefálico antiguo requieren de un seguimiento multidisciplinario que involucre a obstetras, neurocirujanos, neurólogos y otros especialistas, con vistas a evitar las complicaciones que una afección como esta, pueden resultar letales para la madre o el feto(AU)

Cranium cerebral trauma constitutes a silent epidemic for the World Organization of the Health; and specifically skull fractures have risen incidence in the modern society. To present the case of a pregnant woman with an old cranial fracture (front fracture-sinking) that conditions the indication of elective caesarean operation. In addition, it is an unusual anatomical involvement in Obstetrics practice. We present the case of a 22 year-old pregnant that suffered encephalic skull trauma at the age of 4. This trauma is the result of her falling accidentally from a fourth floor to a heavy ceramic recipient and she impacted the front region of her skull. She was unconscious and bled profusely. She underwent urgent surgery. She survived without clinical sequel of cerebral damage but she has cranial sinking deformity in a well-defined oval way. Elective caesarean operation is determined by orientation from the national infantile maternal program to the 40,5 weeks, weight of the newly born 3 802 grams, Apgar 9-9. Satisfactory evolution during their prenatal attention and puerperium. Elective cesarean section is determined at 40.5 weeks, the newborn weight 3 802 g, Apgar 9-9, in alignment with the Cuban national program for the mother and the child. She had a satisfactory evolution during her prenatal and puerperal care. The assessment and management of a pregnant woman with a history of an old cranioencephalic trauma requires multidisciplinary monitoring involving obstetricians, neurosurgeons, neurologists and other specialists, for avoiding complications which can be lethal to the mother or the fetus(AU)

Morphometry of the occipital condyle and basilar process of Nigerian skulls

Background: Effective surgical approaches and conclusive forensic investigations will require a well-documented comparative data for specific regions. This study was carried out to generate Nigerian specific morphometric data for the occipital condyle and basilar process and evaluate its application in forensic and clinical anatomy using macerated skull bones. Methods: A total of 141 adult Nigerian skull bones comprising of 126 males and 15 females were used for this study. Side specific (left [L] and right [R]) morphometric measurements were taken for the occipital condyle [OC] (length, maximum and minimum width [Mx OC & MnOC width], post and anterior intercondyle distance [AICD and PICD]). OC morphology was determined by shape and analysis was carried out using the Statistical package for Social Sciences (SPSS IBM® version 23) t-test was used in assessing sex differences in the measured parameters with confidence level set at 95% and P<0.05 was considered significant. Results: The result obtained showed an equal distribution of oval and oblong shaped OC (27% for both), with less frequent crescentic shaped OC (19.9%). The mean (± S.D) of studied parameters were; L-OC Length = 20.98 ± 1.88mm, R-OC length = 20.52 ± 1.93mm, L-MxOC width = 15.11 ± 1.53mm, R-MxOC width = 14.26 ± 1.59mm, L-MnOC width = 10.85 ± 1.23mm, R-MnOC width = 10.76 ± 1.30mm, AICD = 18.09 ± 2.15mm, PICD = 30.85 ± 2.98mm and BP length = 29.37 ± 3.85mm. The paired sample t-test showed that only the MnOC width was bilateral, while OClength and MxOC width were significantly asymmetrical (P<0.001).The t-test showed that all variables except for OC length and MnOC width were significantly larger in males (P<0.05). When the dimensions of the Nigerian skull were compared with foreign values, high racial variability was observed and we had average OC length; not very short neither long, which was relatively safe for OC resection during surgical intervention at that region. Conclusion: It could be concluded that sex, side and racial differences are observable features of the occipital condyle and its morphometric relationship to other structures are useful to forensic experts and surgeons

Bilateral Cranial IX and X Nerve Palsies After Mild Traumatic Brain Injury

We report a 57-year-old man with bilateral cranial nerve IX and X palsies who presented with severe dysphagia. After a mild head injury, the patient complained of difficult swallowing. Physical examination revealed normal tongue motion and no uvular deviation. Cervical X-ray findings were negative, but a brain computed tomography revealed a skull fracture involving bilateral jugular foramen. Laryngoscopy indicated bilateral vocal cord palsy. In a videofluoroscopic swallowing study, food residue remained in the vallecula and pyriform sinus, and there was reduced motion of the pharynx and larynx. Electromyography confirmed bilateral superior and recurrent laryngeal neuropathy.

Diplejía facial en adultos angolanos / Facial diplejia in Angolan adults

Se presentan 3 casos clínicos de pacientes con diplejía facial, quienes acudieron al Servicio de Urgencias del Hospital Provincial "Dr. Agostinho Neto" de la República Popular de Angola. A pesar de no disponerse de todos los recursos materiales necesarios, el diagnóstico precoz de dicha alteración permitió la adecuada valoración y el tratamiento oportuno de los afectados.

Three case reports of patients with facial diplejia, assisted in "Dr. Agostinho Neto" Emergency Service in the Provincial Hospital from the People's Republic of Angola, where Cuban medical staff worked are presented. In spite of having scarcity of all the necessary material resources, the early diagnosis of this change allowed the appropriate evaluation and the opportune treatment of those patients affected.

Fratura de osso temporal em pacientes com traumatismo crânio-encefálico / Fracture of the temporal bone in patients with traumatic brain injury

INTRODUÇÃO: As fraturas de osso temporal são lesões que se observam em pacientes com traumatismo crânio-encefálico (TCE).A tomografia computadorizada de alta resolução (TC) permite avaliar a fratura e as complicações. OBJETIVO: Avaliar pacientes com TCE e fratura de osso temporal. FORMA DE ESTUDO: Estudo retrospectivo. MÉTODO: Foram avaliados 28 pacientes internados por TCE com evidência clínica e/ou radiológica de fratura de osso temporal. RESULTADOS: A faixa etária variou 3 a 75 anos O lado mais afetado foi o direito 50% (n=14), esquerdo 36% (n=10) e bilateral 14% (n=4). A etiologia do trauma foi queda 25% (n=7), acidentes com motocicletas e bicicletas 21% (n= 6), agressão física 14% (n= 4), atropelamento 11% (n=3), queda de objeto 4% (n=1) e outras causas 25% (n=7). Os sinais clínicos foram: otorragia 78% (n=22), otalgia 11% (n=3), otorreia 7% (n=2), paralisia facial 7% (n=2) e hipoacusia 7% (n=2). Os achados a otoscopia: otorragia 57% (n=16), laceração de conduto auditivo externo 36% (n=10), hemotímpano 11% (n=3), normal 7% (n=2) e sinal de Battle 7% (n=2). Os achados à TC de crânio foram: sem alterações 54%(n=15) e fratura de temporal 7% (n=2) e na TC de ossos temporais foram: linha de fratura 71% (n=20), velamento da mastoide 25% (n=7), ar em cavidade glenóidea 14% (n=4), luxação de cadeia ossicular 7% (n=2) e velamento orelha média 4% (n=1). CONCLUSÃO: Pacientes com TCE devem ser submetidos à avaliação otorrinolaringológica e de imagem, para diagnóstico precoce das complicações e tratamento.

INTRODUCTION: The fractures in the temporal bone are lesions that are observed in patients with traumatic brain injury (TBI). The computed tomography of high-resolution (CT) allows evaluating the fracture and the complications. OBJECTIVE: Evaluate patients with TBI and temporal bone fracture. WAY OF STUDY: Retrospective study. METHOD: Were evaluated 28 patients interned by TBI with clinical evidence and/or radiologic from temporal bone fractures. RESULTS: The age ranged from 3 to 75 years. The most affected side was the right side 50% (n=14), left side 36% (n=10) and both sides 14% (n=4). The etiology of the trauma was the falling 25% (n=7), accidents with motorcycles and bicycles 21% (n=6), physical aggression 14% (n=4), running over 11% (n=3), fall of object 4% (n=1) and other causes 25% (n=7). The clinical signs were: Otorrhagia 78%, otalgia 11% (n=3), otorrhea 7% (n=2), facial paralysis 7% (n=2) and hearing loss 7% (n=2). The otoscopic findings: otorrhagia 57% (n=16), laceration of external auditory canal 36% (n=10), hemotympanum 11% (n=3), normal 7% (n=2) and Battle signal 7% (n=2). The findings for CT of skull were: with no alterations 54% (n=15) and temporal fracture 7% (n=2) and the CT of temporal bones were: line of fracture 71% (n=20), opacification of the mastoid 25% (n=7), glenoid cavity air 14% (n=1), dislocation of the ossicular chain 7% (n=2) and veiling of the middle ear 4% (n=1). CONCLUSION: Patients with TBI must be submitted to the otorhinolaryngological evaluation and imaging, for the early diagnosis of the complications and treatment.

Relación entre las fracturas de base craneal y la electronistagmografía / Relation between the cranial base and the electro-nystagmography

Introducción: la electronistagmografía se usa en la actualidad con fines de diagnóstico, es el proceso por el cual se hace un registro de la posición y movimiento del globo ocular, para identificar cambios en el campo eléctrico alrededor del ojo al modificar su posición. Objetivo: evaluar la utilidad de la electronistagmografía, al compararla con la prueba vestibular tradicional para el diagnóstico topográfico de las secuelas audiológicas vestibulares presentes en pacientes con fractura de base craneal. Métodos: se realizó un estudio observacional, analítico, de corte transversal, en el Hospital Militar Dr Carlos Juan Finlay, en el período comprendido de enero de 2006 a enero de 2008. El universo estuvo representado por 210 pacientes, divididos en 2 grupos: uno de estudio con secuelas auditivas vestibulares posteriores a fractura de base de cráneo, y otro de control, con sujetos sanos. Resultados: el síntoma que se encontró en el 100 por ciento de los pacientes fue el vértigo. Del total de 118 casos con electronistagmografía positiva, 47 (39,8 por ciento) habían arrojado resultados negativos en la prueba vestibular. Conclusiones: la electronistagmografía resultó positiva en el mayor número de casos estudiados, y presentó una alta sensibilidad, al demostrar, que casos con debilidad laberíntica y preponderancia direccional presentes, no fueron diagnosticados con la prueba vestibular tradicional(AU)

Introduction: nowadays, the electro-nystagmography is used for diagnosis; it is the process by which it is possible to register the position and movement of ocular eyeball to identify the changes in the electric field around the eye in modifying its position. Objective: to assess the usefulness of the electro-nystagmography in comparison with the traditional vestibular test for topographic diagnosis of auditory sequelae present in the patients presenting with cranial base fracture. Methods: a cross-sectional, analytical and observational study was conducted in the Dr Carlos J Finlay Military Hospital from January, 2006 to January, 2008. Universe included 210 patients divided into two groups: a study group with vestibular auditory sequealae after a fracture of cranial base and a control group consisting of healthy subjects. Results: dizziness was the symptom present in the 100 percent of patients. From the total of 118 cases with positive electro-nystagmography, 47 (39.8 percent) had negative results in the vestibular test. Conclusions: the electro-nystagmography was positive en most of study cases with a high sensitivity demonstrating that cases presenting with labyrinth weakness and directional predominance were not diagnosed by means of traditional vestibular test(AU)

Fracturas del clivus / Clivus fractures

Las fracturas de base de cráneo se encuentran entre el 3.5 y el 24 por ciento de los pacientes con trauma craneoencefálico. Las fracturas del clivus, se consideran fracturas de la base craneana posterior y se clasifican en longitudinales, transversas y oblicuas. El diagnóstico de estas fracturas ha aumentado con el uso del TAC de cráneo. Anteriormente su diagnostico se realizaba con mayor frecuencia en autopsias. Las fracturas del clivus con gran frecuencia se asocian a lesión de estructuras neurológicas y vasculares vecinas, tienen un mal pronóstico neurológico aunque se han descrito casos asintomático de fracturas clivales. En este artículo se reportara nuestra experiencia con esta patología traumática y se hará una revisión de la literatura.

Skull base fractures are found in 3.5 to 24 percent of all traumatic brain injury. Clivus fracture is considered a posterior skull base fracture and is classified into longitudinal, transversal and oblique. The finding of these fractures had incremented with the use of CT scans. Previously the diagnosis of clival fractures was made mostly at autopsy studies. Clival fractures are associated with injuries to nervous and vascular structures in its vicinity. These fractures have a bad neurological prognosis although there are cases of asymptomatic patients with clival fractures in the scientific literature. In this article we will repot our experience with this traumatic pathology and we will review the literature.

Fractura de base de cráneo en recién nacidos: caso clínico / Basal fracture of the skull in a newborn: case report and review of the literature

Introduction: Reported incidence of cranial lesions in childbirth is about 1.7 to 59 per 10,000 births. Among these, fracture of the base of the skull is rare but serious due to sequelae and mortality. Objective: Describe a case of a newborn with a fracture of the temporal bone, review diagnosis and management of skull fractures. Clinical Case: The patient was born with assistance, use of forceps, showed deviation of the buccal commisure and otorrhagia on the left side during puerperium. CT Sean detected fracture of the base of the cranium at the level of the temporal bone. Hemogram, cultures and spinal fluid studies were done. Prophylactic therapy was initiated. All blood studies were negative and follow up studies were normal. Discussion: Literature reviews support the diagnosis to be confirmed through a CT sean, and an active search for meningitis be started through hemocultures, hemogram, and Cerebrospinal Fluid. Management should be conservative, evaluating the need for an LR Evidence shows that antibiotic prophylaxis for meningitis has little indication in these cases.

Introducción: La incidencia de lesiones de cráneo en recién nacidos reportadas son del orden de 1,7 a 59 por 10 000 nacimientos. Dentro de estas, las fracturas de base de cráneo son eventos poco frecuentes, pero de consideración dado su potencial gravedad en cuanto a mortalidad y secuelas. Objetivo: Relatar el caso de un recién nacido con una fractura de peñasco y revisar el diagnóstico y manejo de las lesiones de cráneo. Caso Clínico: El paciente, tras parto instrumentalizado por fórceps, presentó desviación de comisura bucal y otorragia durante su estadía en puerperio. La TAC de cerebro con reconstrucción ósea fue compatible con una fractura de base de cráneo (peñasco izquierdo). Se tomaron hemocultivo, hemograma y PCR y se inició antibioticoterapia profiláctica para meningitis. Evolucionó favorablemente con hemocultivos negativos, hemograma y PCR normales, TAC de control sin cambios y examen neurológico normal. Discusión: La literatura recomienda que el diagnóstico de fractura de base de cráneo debe ser confirmado por medio de TAC de cerebro y que debe realizarse una búsqueda activa de meningitis por medio de hemocultivos, hemograma y PCR, evaluar la necesidad de punción lumbar y manejar en forma conservadora. La evidencia señala que la profilaxis antibiótica para meningitis en estos pacientes no tiene indicación.

Extraordinarily Long-Term Posttraumatic Cerebrospinal Fluid Fistula

Most posttraumatic cerebrospinal fluid (CSF) leakage is noticed by the patients with the first symptom, rhinorrhea. A 38-year-old woman presented with frequent clear continuous rhinorrhea and otorrhea for 5 years after basilar skull fracture. After this, meningitis was developed with subsequent CSF fistula. Her clinical symptom was improved by medical treatment. The dural defect and CSF leakage were not detected by computerized tomography (CT) cisternography. We report a rare case of persistent posttraumatic CSF fistula that continued for five years.

Bléfaro-hematoma, otorragia e sinal de Battle como indicadores de Fratura de base do crânio e de lesões intracranianas / Blepharohaematoma, bloody otorrhea and Battle's sign as indicators of basal skul fracture and intracranial lesions

Fraturas de base de crânio são freqüentes após traumas craniais. Sugere-se que tais fraturas sejam sinalizadoras de importante risco de complicações, além de causar perda transitória da consciência. De acordo com a experiência dos autores, bléfaro-hematoma, otorragia e sinal de Battle são sinais comuns, indicadores desse tipo de fratura e de lesões intracraniais, mesmo em pacientes com índice de 13 a 15 na escala de coma de Glasgow. Nesses casos, sugere-se indicar tomografia computadorizada, com janela óssea, em busca de lesões associadas.

Traumatismo encefálico con fractura de cráneo. Tratamiento médico y quirúrgico. Reporte de un caso / Head trauma with a skull fracture. Medical and surgery assessment. Case Report

Se presenta al Consultorio Veterinario de la Universidad de Antioquia una perra de raza Pinsher miniatura de 6 años, con convulsiones tónico clónicas y en estado de delirio, después de sufrir un fuerte traumatismo ocasionado por el ataque de otro perro. A la exploración física se detecta una fractura en el cráneo, que luego fue confirmada por radiología. Se instaura tratamiento médico encaminado a reducir la presión intracraneal. Al no mejorar neurológicamente se somete a cirugía. Este procedimiento permitió la mejoría del paciente y la posterior recuperación total de los síntomas neurológicos, sin que hasta la fecha se hayan presentado secuelas del incidente.

Clinical Analysis of Basilar Skull Fracture (BSF)

188 consecutive cases with basilar skull fractures(BSF) out of 2676 head injury patients who were treated in Chung-Ang Gil Hospital from July 1993 to June 1995, were analyzed. These fractures are difficult to diagnose by ordinary X-ray examinations, routine head computed tomography(CT) and are frequently inferred by clinical signs. Therefore, it's diagnosis is somtimes delayed or missed in initial assessment of trauma patients. They are different from cranial vault fractures in several aspects other than difficulties in the diagnosis. It involves more commonly the cranial nerves(CN), makes cerebrospinal fluid(CSF) fistulae and leads to central nervous system(CNS) infections if the CSF fistulae are not detected or treated early and properly. The authors reviewed the clinical features, radiological findings, rate of delayed diagnosis, complications and outcomes. The most common feature of BSF was otorrhea(64.4%) and followed by rhinorrhea(39.4%), raccoon eye(32.4%) and hemotympanum(24.5%). In only 6.4% of cases, the fracture lines were detected by ordinary skull radiographs and diagnosed as BSF. In contrast, the high resolution skull base CT confirmed the fractures in 62.2%. Clinical diagnoses were made in 14.9%. Commonly combined craniofacial lesions were cranial vault fractures(51.1%), intracranial hemorrhages(46.3%), and facial bone fractures(34.0%). Most of CSF leakages(89.7%) were noted within 24 hours after injury and most of the leakages (87.7%) had ceased by conservative management within 2 weeks, but 5.1% that did not respond to conservative treatment and lumbar CSF drainage, needed invasive operative repair. The incidence of meningitis was 3.2% and the prophylactic antibiotics had no benificial effect on lowering the infection rate. Facial nerve was the most frequently involved cranial nerve followed by vestibulo-cocchlear, oculomotor, and olfactory nerve in decreasing order of frequency. The onset of facial palsy was immediate in 31.8% and the remainder were delayed more than 24 hours after head injury. Of 188 patients, 21 cases(11.2%) were delayed in the diagnosis of BSF.

Traumatic Pneumocephalus Diagnosed with Computerized Tomography(CT)

Although moderate amounts of pneumocephalus can be easily identified on routine skull films, very small amounts of air can be easily diagnosed and its location correctly assessed only by computerized tomography. The identification of even a small air collection should alert the clinician to the likelihood of a basilar skull fracture and its potentially serious sequelae such as tension pneumocephalus or meningitis. Authors report and summarize 11 cases of traumatic peumocephalus diagnosed with CT scan.