Timing of cranioplasty after decompressive craniectomy for trauma.

BACKGROUND: The optimal timing of cranioplasty after decompressive craniectomy for trauma is unknown. The aim of this study was to determine if early cranioplasty after decompressive craniectomy for trauma reduces complications. METHODS: Consecutive cases of patients who underwent autologous cranioplasty after decompressive craniectomy for trauma at a single Level I Trauma Center were studied in a retrospective 10 year data review. Associations of categorical variables were compared using Chi-square test or Fisher's exact test. RESULTS: A total of 157 patients were divided into early (<12 weeks; 78 patients) and late (≥12 weeks; 79 patients) cranioplasty cohorts. Baseline characteristics were similar between the two cohorts. Cranioplasty operative time was significantly shorter in the early (102 minutes) than the late (125 minutes) cranioplasty cohort (P = 0.0482). Overall complication rate in both cohorts was 35%. Infection rates were lower in the early (7.7%) than the late (14%) cranioplasty cohort as was bone graft resorption (15% early, 19% late), hydrocephalus rate (7.7% early, 1.3% late), and postoperative hematoma incidence (3.9% early, 1.3% late). However, these differences were not statistically significant. Patients <18 years of age were at higher risk of bone graft resorption than patients ≥18 years of age (OR 3.32, 95% CI 1.25-8.81; P = 0.0162). CONCLUSIONS: After decompressive craniectomy for trauma, early (<12 weeks) cranioplasty does not alter the incidence of complication rates. In patients <18 years of age, early (<12 weeks) cranioplasty increases the risk of bone resorption. Delaying cranioplasty (≥12 weeks) results in longer operative times and may increase costs.

Timing of cranioplasty after decompressive craniectomy for ischemic or hemorrhagic stroke.

OBJECT: The optimal timing of cranioplasty after decompressive craniectomy for stroke is not known. Case series suggest that early cranioplasty is associated with higher rates of infection while delaying cranioplasty may be associated with higher rates of bone resorption. The authors examined whether the timing of cranioplasty after decompressive craniectomy for stroke affects postoperative complication rates. METHODS: A retrospective cohort study was undertaken to evaluate complication rates in patients undergoing cranioplasty at early (within 10 weeks of craniectomy) or late (≥ 10 weeks) stages. Multivariate logistic regression analysis was used to determine characteristics that would predict complications in patients undergoing cranioplasty after decompressive craniectomy for stroke. RESULTS: While the overall complication rate was higher in the early cranioplasty cohort (22% vs 16% in the late cranioplasty cohort), the difference was not statistically significant (p = 0.5541). Patients in the early cranioplasty cohort had lower rates of postoperative hematoma but higher rates of infection. Presence of a CSF shunt was the only significant predictor of complications (OR 8.96, 95% CI 1.84-43.6). CONCLUSIONS: Complications rates for early cranioplasty (within 10 weeks of craniectomy) are similar to those encountered when cranioplasty is delayed, although the cohort size in this study was too small to state equivalence. Patients with a ventriculoperitoneal shunt are at higher risk for complications after cranioplasty.

Optimal timing of autologous cranioplasty after decompressive craniectomy in children.

OBJECT: The object of this study was to determine if early cranioplasty after decompressive craniectomy for elevated intracranial pressure in children reduces complications. METHODS: Sixty-one consecutive cases involving pediatric patients who underwent autologous cranioplasty after decompressive craniectomy for raised intracranial pressure at a single academic children's hospital over 15 years were studied retrospectively. RESULTS: Sixty-one patients were divided into early (< 6 weeks; 28 patients) and late (≥ 6 weeks; 33 patients) cranioplasty cohorts. The cohorts were similar except for slightly lower age in the early (8.03 years) than the late (10.8 years) cranioplasty cohort (p < 0.05). Bone resorption after cranioplasty was significantly more common in the late (42%) than the early (14%) cranioplasty cohort (p < 0.05; OR 5.4). No other complication differed in incidence between the cohorts. CONCLUSIONS: After decompressive craniectomy for raised intracranial pressure in children, early (< 6 weeks) cranioplasty reduces the occurrence of reoperation for bone resorption, without altering the incidence of other complications.

Optochiasmatic cavernous hemangioma.

We present a case of an optochiasmatic cavernous hemangioma (OCH) treated by stereotactic radiotherapy that required subsequent surgical resection. Subtotal resection and/or radiotherapy are not curative and can lead to hemorrhage and progressive neuronal insult. We recommend complete surgical resection as the treatment of choice.

Anterior screw fixation of a dislocated type II odontoid fracture facilitated by transoral and posterior cervical manual reduction.

BACKGROUND: Early fixation of type II odontoid fractures has been shown to provide high rates of long-term stabilization and osteosynthesis. CASE: In this report, the authors present the case of a patient with a locked type II odontoid fracture treated by anterior screw fixation facilitated by closed transoral and posterior cervical manual reduction. CONCLUSION: While transoral intraoperative reduction of a partially displaced odontoid fracture has previously been described, the authors present the first case utilizing this technique in the treatment of a completely dislocated type II odontoid fracture.

Primary melanocytic tumor of the cerebellopontine angle mimicking a vestibular schwannoma: case report.

OBJECTIVE: The majority of tumors of the cerebellopontine angle (CPA) are benign. We report the case of a primary malignant melanoma of the CPA that mimicked a vestibular schwannoma (acoustic neuroma). We discuss the differential diagnosis and prognosis of melanotic lesions at this location. CLINICAL PRESENTATION: A 49-year-old man presented with a 7-year history of unilateral deafness and a several month history of imbalance, intractable nausea and vomiting, as well as weight loss. A neurological work-up revealed a large tumor in the left CPA radiographically diagnosed as a vestibular schwannoma. INTERVENTION: A translabyrinthine approach revealed a pigmented, vascular neoplasm encasing vessels and cranial nerves of the left CPA. The tumor was subtotally resected, and a histopathological diagnosis of melanoma was made. The patient had no history of cutaneous melanoma and no other site of disease was ever discovered. CONCLUSION: This case most likely represents primary melanoma of the central nervous system that mimicked a vestibular schwannoma. The differential diagnosis of melanotic lesions of the CPA is discussed as are the prognostic implications of each diagnosis.

Evaluation of microporous polysaccharide hemospheres for parenchymal hemostasis during laparoscopic partial nephrectomy in the porcine model.

OBJECTIVES: We evaluated the efficacy of Microporous Polysaccharide Hemospheres (MPH) for parenchymal hemostasis during laparoscopic partial nephrectomy (LPN) in the porcine model. METHODS: Six female farm pigs underwent a transperitoneal right lower-pole LPN during occlusion of the renal hilum. Renal parenchyma was excised using cold Endoshears. MPH was applied to the defect and the hilar clamp released. Animals were kept alive for one week. Before sacrifice, left LPN was similarly performed using MPH. Study variables included blood loss, number of MPH applications, hilar clamp time, hemostasis time, perioperative complications, and abnormalities noted at sacrifice. RESULTS: Hemostasis was achieved in all kidneys solely by using MPH. The average excised specimen represented 5.6% (range, 3.6 to 8.5) of renal weight. Mean hilar clamp and hemostatic times were 12.8 minutes (range, 6 to 18) and 2 minutes (range, 1 to 3), respectively. Hemostasis occurred after one MPH application in 8 kidneys (67%). In 3 kidneys, additional MPH powder was required to treat minor residual bleeding. In the remaining kidney, a second standard MPH application was required for hemostasis. No operative complications were encountered. No hematomas or residual MPH was found at necropsy; however, small urinomas were found in 2 of 6 kidneys. CONCLUSIONS: In the experimental porcine model, this initial study suggests that MPH provides effective parenchymal hemostasis during laparoscopic resection of an exophytic kidney lesion.

Resolution of diabetes insipidus following gamma knife surgery for a solitary metastasis to the pituitary stalk. Case report.

The authors present the case of a 58-year-old woman who presented with symptoms of diabetes insipidus (DI) 1 year after she was found to have a Stage 3 (of 4) estrogen receptor-positive infiltrating ductal adenocarcinoma of the left breast with pulmonary and bone metastases. Magnetic resonance images demonstrated a solitary site of metastasis in the patient's pituitary stalk, and gamma knife surgery (GKS) was performed to treat the lesion. Three months after GKS the patient was able to reduce the medication she required for the DI. There was no evidence of pituitary failure and no negative effect on her vision.

Evaluation of microporous polysaccharide hemospheres as a novel hemostatic agent in open partial nephrectomy: favorable experimental results in the porcine model.

PURPOSE: Microporous polysaccharide hemospheres (MPH, Medafor, Minneapolis, Minneapolis) are a novel hemostatic agent made from purified plant starch. MPH activates the clotting cascade and hyperconcentrates platelets and coagulation proteins, while enhancing a hemostatic plug. We evaluated the hemostatic efficacy of MPH compared with standard surgical technique in a porcine open partial nephrectomy model. MATERIALS AND METHODS: Standardized lower pole partial nephrectomy was consecutively performed in each kidney of 12 female pigs. Each pig was randomized to 2 groups, namely treatment with MPH application or control with the conventional surgical technique (oxidized cellulose with bolster sutures). The right kidney was harvested 1 half-hour after hemostasis was achieved and the left kidney was harvested after 7 days. RESULTS: Mean animal and resected renal tissue weight were comparable. Ischemic and hemostasis times were significantly decreased in the MPH treated group (2.67 and 4.67 minutes, respectively) vs the control group (8.33 and 7.75 minutes, respectively) (each p = 0.004). Blood loss was equivocal (0.88 gm in the treatment group vs 2.09 gm in the control group, p = 0.07). No hemostatic complications were noted in either group. No evidence of residual foreign material was found in the MPH group at 1 week. CONCLUSIONS: MPH provided rapid, effective and durable hemostasis in the porcine open partial nephrectomy model. Additional experimental and clinical evaluation is warranted to define the role of MPH assisted partial nephrectomy in humans.