Anatomical cerebellar protection of contrecoup hematoma development. Analysis of the mechanism of 30 posterior fossa coup hematomas.

The aim of this paper is to present the topographical/anatomical conditions that protect the posterior fossa from posterior fossa hematoma (PFH) resulting from contrecoup mechanisms and to point out the value of neuroradiological findings in determining force direction and transition. The biomechanism of this clinical entity also plays an important role in correct forensic interpretation. Generally, PFH are rare. In our series, they occurred exclusively as a result of forces applied to the occipital region. However, their appearance as a result of contrecoup mechanisms is exceptional. Considering the particular anatomical traits that protect the posterior fossa from the force transition of fronto-occipital (F-O) direction we put forth seven hypotheses which should explain the low incidence of PFH. Between 1989 and 1998, we treated 523 patients with intracranial hematomas caused by blunt trauma. Among them were 30 patients with PFH. All of them sustained an occipital bone fracture, confirming the coup lesion. In conclusion, it is difficult to determine clinically whether forces in the F-O direction could produce PFH as a result of contrecoup mechanism. That could be only proven in vivo by neuroradiological findings.

Successful treatment of traumatic acute posterior fossa subdural hematoma: report of two cases.

BACKGROUND: Acute traumatic subdural hematoma of the posterior cranial fossa after a closed-head injury, excluding those in newborns, is a very rare clinical event. Generally, the outcome is poor and the overall mortality rate is high. METHODS: Acute posttraumatic subdural hematomas of the posterior fossa associated with acute hydrocephalus in two patients were removed by standard suboccipital approach. Preoperatively, one patient was in a coma and the Glasgow Coma Score was 9 in another. CT scans showed obliterated mesencephalic cisterns in both cases. In the former there was a complex posterior fossa lesion, i.e., combined subdural and intracerebellar hematoma. The surgical decompression was completed 3 and 11 hours after injury, respectively. Intraoperative tapping of the lateral ventricle through a burr hole in the occipital area was performed in the latter case. RESULTS: Both patients survived; one made a good recovery, (i.e., Glasgow Outcome Scale 4 in a patient who was comatose on admission), the other did not do as well (GOS 3). CONCLUSIONS: Our experience justifies the policy of mandatory early operation in cases of traumatic acute subdural hematoma of the posterior fossa associated with poor neurologic condition, even in patients of advanced age. In patients with obliterated mesencephalic cisterns and/or complex posterior fossa lesions the same approach must be followed. These clinical and CT features are not necessarily predictors of a poor outcome.

[Therapeutic outcome in penetrating craniocerebral injuries in children. Personal experiences during war conditions]. / Therapeutische Ergebnisse bei penetrierenden kraniozerebralen Verletzungen von Kindern. Unsere Erfahrungen unter Kriegsverhältnissen.

During the war period 1991-1992 in Croatia, ten wounded children (16 years of age or younger) with war injuries to the brain were admitted to the Division of Neurosurgery, Osijek Clinical Hospital. Six of them had been wounded by shrapnel and four by pistol or rifle bullets. All but one were managed surgically (i.e. by craniotomy). The outcome was: as follows three children had a good recovery, four retained a moderate neurological deficit, and three died (injured by shrapnel). Five of the wounded (four injured by shrapnel and one by bullets) had associated injuries (fractures of the leg bones, eye lesion, amputation of the right leg) which influenced morbidity, and in one case mortality. Children wounded with shrapnel had brain edema on admission to hospital. Our experience indicates that the thermal effect from heated shrapnel, as well as velocity, mass, size and shape of the shrapnel, could be an additional factor for the development of severe brain edema.

Cor triatriatum dextrum--an unusual variant of triatrial heart.

The present report describes a rare case of triatrial heart, cor triatriatum dextrum in a 31-year-old woman in whom the anomaly was incidentally detected by radionuclide angiocardiography. Subsequent assessment with two-dimensional echocardiography and right heart catheterization confirmed the presence of a membrane subdividing the right atrium into two distinct chambers. To the best of our knowledge, this is the only case in which this cardiac anomaly was demonstrated by radionuclide technique.

[Myelography, CT scan, electromyography and neurologic examination in the diagnosis of herniated lumbar disk]. / Vrijednosti mijelografskog i CT prikaza, elektromiografskog i neuroloskog pregleda u dijagnostici hernije lumbalnog diska.

The research was carried out at the Clinical Hospital Osijek during a three-year period. Sixty-nine patients (34 men and 35 women) with the diagnosis of lumbar slipped disc who underwent surgery were followed up. The main inclusion criterion was the surgical finding of hernia. The aim of the study was to obtain a clearer insight into the values of the myelography and CT scan by observing a sufficiently large number of patients with surgically verified hernia of lumbar disc. The characteristics of neurological and EMG findings were surveyed, as well. Thirty-one patients were at the age of 40-49 years and 21 were at 30-39 years of age. Only 5 hernias were at the level L3L4, 28 at the level L4L5, and 46 at the level L5S1. Sensitivity, specificity and overall accuracy of the observed parameters were estimated for 41 leftwards and 30 rightwards located hernias. Myelographic finding, regardless of the observed level of slipped disc, showed excellent sensitivity, specificity and accuracy of diagnosis. CT finding was slightly less sensitive at the level L4L5, it was 0.93, and specific at the level L5S1, amounting to 0.90. Its accuracy was not substantially lower than that of myelography. The pathological EMG was 0.88 sensitive, 0.83 specific and 0.84 accurate. The accuracy was excellent at the level L3L4, it was 0.96, but only very good at the level L5S1, amounting to 0.76. A t-test of linked pairs was used to compare surgical reports and diagnostic findings. There was a great similarity between a CT finding and surgical one in all three levels (t-values 1.00, 0.21 and 0.36). Myeolography was more congruent with the surgical finding in the middle level (t-values 1.65, 0.93 and 1.52). An EMG finding was significantly different from that found by surgery (t-values 1.71, 1.76 and 2.71). The existence of Lasègue's sign for the diagnosis of hernia was 0.93 sensitive, 0.07 specific (remarkably low) and 0.36 accurate. It was particularly inaccurate at the level L3L4, moderately accurate at the level L4L5, and rather accurate at the lowest level L5S1. The weakened Achilles tendon reflex was less sensitive than Lasègue's sign, amounting to 0.80. Its specificity was 0.19 and accuracy 0.40. The highest accuracy was in hernias of the lower two levels L4L5 and L5S1. The existence of weakened sense was 0.91 sensitive, specificity was remarkably low, amounting to 0.08, and accuracy was 0.36. It was most inaccurate at the level L3L4 and slightly better at the levels L4L5 and L5S1. Disturbance of leg movements showed sensitivity of only 0.60, but specificity was 0.39 and accuracy 0.46. It was most precise at the level L4L5. Neurological symptoms and signs were insufficiently sensitive and specific for the diagnosis of lumbar disc hernia. On the basis of these parameters, the level of hernia could not be exactly determined.