Giant scalp arteriovenous malformation / Malformação arteriovenosa gigante de escalpo

SUMMARY Arteriovenous malformations (AVMs) of the scalp are rare lesions. The clinical picture presents with complaints of increased scalp, scalp disfigurement, pain and neurological symptoms. Its origin can be congenital or traumatic. We present a case of giant scalp AVMs and its management, followed by a brief literature review on the subject. The diagnosis of scalp AVMs is based on physical examination and confirmed by internal and external carotid angiography or computed tomographic angiography (CTA). Surgical excision is especially effective in scalp AVMs, and is the most frequently used treatment modality.

RESUMO Malformações arteriovenosas (MAV) do couro cabeludo são lesões raras. O quadro clínico apresenta-se com queixas de aumento do couro cabeludo, desfiguração do couro cabeludo, dor e sintomas neurológicos. A origem pode ser congênita ou traumática. Apresentamos um caso de MAV gigante de couro cabeludo e o tratamento adotado, seguindo-se uma breve revisão da literatura. O diagnóstico das MAV de couro cabeludo baseia-se no exame físico e é confirmado pela angiografia carótida interna e externa ou angiografia por tomografia computadorizada. A excisão cirúrgica é especialmente eficaz em MAV de couro cabeludo e é a modalidade de tratamento mais frequentemente utilizada.

Métodos de vigilância fetal intraparto / Methods of intrapartum fetal surveillance

A avaliação do bem-estar fetal durante assistência ao trabalho de parto é um dos principais objetivos da Obstetrícia. O método mais utilizado para essa avaliação é a monitorização eletrônica fetal contínua. Em razão de sua limitada capacidade diagnóstica, outros métodos complementares têm sido investigados para esse fim, como a ausculta intermitente, a estimulação digital no escalpe fetal, a oximetria de pulso, o eletrocardiograma fetal e a coleta de amostras de sangue do couro cabeludo fetal. Após revisão da literatura, foi concluído que são necessários mais estudos para determinar a verdadeira utilidade, na prática clínica, dos métodos complementares à monitorização eletrônica fetal contínua para avaliação fetal intraparto.

The evaluation of intrapartum fetal well-being is one of the main objectives of Obstetrics. The most used method for this assessment is the continuous electronic fetal monitoring. Because of their limited diagnostic capabilities, other complementary methods have been investigated for evaluation of intrapartum surveillance, as intermittent auscultation, digital fetal scalp stimulation, pulse oximetry, fetal electrocardiogram and fetal scalp blood sample. After a review of articles, we concluded that more studies are needed to determine the true usefulness in clinical practice of complementary methods to continuous electronic fetal monitoring for intrapartum fetal monitoring.

Scalp arteriovenous malformations.

AIMS: We discuss our experience with the surgical management of scalp vascular malformation and review the literature on the subject. SETTINGS AND DESIGN: A prospective case-control study of eight patients with scalp vascular malformations admitted to our hospital between 1997 and 2002. METHODS AND MATERIALS: All the patients were investigated with selective internal and external carotid angiography. Depending upon the origin of feeding arteries, the scalp vascular malformations were classified into two categories: Group I: the primary scalp arteriovenous malformations and Group II: secondary venous dilatations. Six patients belonged to Group I and two patients were in Group II. RESULTS: Five patients belonging to Group I underwent successful excision of the arteriovenous malformation. There was no recurrence in this group. Of the two patients in Group II, one patient who had scalp vascular dilatation simulating a primary scalp vascular malformation underwent excision of the lesion. This patient developed severe postoperative brain edema and died. CONCLUSIONS: Primary scalp vascular malformation can be excised safely. However, excision of secondary scalp venous dilatation without treatment of the intracranial component can be dangerous.

Hemodynamic response to skull pins application in children: effect of lignocaine infiltration of scalp.

BACKGROUND: Skull pins application following local anesthetic infiltration of scalp obtunds hemodynamic changes in adults. No such study is available in children. METHODS: 30 children undergoing elective suboccipital craniectomy with skull pins fixation, were randomly allocated either to control group I, or lignocaine group II. Whereas in group I, pins were applied without any scalp infiltration. In group II, pins were applied 1 min. after scalp infiltration with 0.5% lignocaine (plain) at each pin site. RESULTS: Mean arterial pressure and heart rate were recorded during pinning (peak increase),1,4,7 and 10 min later, and were compared with the baseline (parameters recorded approximately 20 min. after intubation). Mean arterial pressure in group I peaked from 77.0 +/- 9.19 to 113.87 +/- 13.7mmHg (P<0.001) and remained significantly high throughout the study period. In Group II peak increase in mean arterial pressure was from 91.64 +/- 16.39 to 101.85 +/- 15.87 mmHg (P<0.01) and remained high till 1 min. only. Pins placement resulted in significant increase in heart rate only during pinning (peak increase) and up to 1 min. in both the groups (P<0.01). CONCLUSIONS: In children, skull pins placement 1 min. after scalp infiltration with 0.5% lignocaine plain fails to prevent the hemodynamic changes arising during pins placement (peak change) and up to 1 min. after pins placement. However, the technique successfully blocks these changes beyond 1 min. post skull pins fixation.

Scalp replantation: a case report of long ischemic time.

A totally avulsed scalp was treated successfully by microvascular replantation in 1975 (1). Since then, scalp replantation has become the treatment of choice in scalp injuries and should always be considered even in cases of severe damage or prolonged ischemic time. Usually, every attempt is made to establish as many vascular anastomoses as possible. We report one case of total scalp avulsion with a 24-hour ischemic time, which was successfully replanted via one arterial and one venous anastomose.

Reconstrucción de cuero cabelludo / Scalp reconstruction

Este artículo de actualización revisa en primer término, brevemente la historia de la reconstrucción de cuero cabelludo y la anatomía en aquellos detalles que son importantes para el cirujano que asume el compromiso de efectuar una reconstrucción de cuero cabelludo. A continuación, se revisa las técnicas quirúrgicas generalmente aceptadas y uso frecuente que pueden aplicarse de acuerdo a la profundidad y l extensión de la pérdida del cuero cabelludo. Por último, se destaca la importancia de realizar siempre una buena planificación en el diseño y manejo de los colgajos utilizados para evitar la pérdida de un recurso de tejidos siempre limitado

Surgical anatomy of the subgaleal fascia of the scalp and its arterial vasculature

The surgical anatomy of the fascial layers and vascularization of the scalp was studied by dissecting ten adult cadavers and two still births. This article is organized as follows: first, a description of the layers and fasciae of the scalp and their relationships with the main vascular structures. Then special attention was directed to the layer of "loose connective tissue" that lies beneath the entire galea and above the cranial periosteum centrally, and the temporalis fascia laterally. It has been named the "subgaleal fascia" which is discrete anatomical entity, thin, malleable and well vascularized. A description of the histological structure of the subgaleal fascia "composed of multiple connective vascularized sheets loosely adherent to one another". Cadaveric dissections revealed its blood supply from the principal vascular pedicles of the scalp [axial blood supply] and from major perforant vessels to the subgaleal fascia as follows: in the temporal region, perforant vessels from the superficial temporal artery near and about ten centimeter above zygomatic arch, and in the fronto-parieto-occipital region, many small perforant vessels evenly entering the subgaleal fascia every five to ten mm. These findings could lead to greater use of fascial or composite flaps from the scalp region