[Case of pseudoankylosis of the mandible after craniotomy].

Craniotomy sometimes causes pseudoankylosis of the mandible, i.e., limited mouth opening, leading to a difficult airway. We describe a case of difficult airway due to pseudoankylosis of the mandible after craniotomy, in which orotracheal intubation was successfully performed with an AirWay Scope (AWS). A 60-year-old woman was scheduled for clipping of an unruptured cerebral aneurysm. She had undergone emergency clipping of a ruptured cerebral aneurysm under frontotemporal craniotomy on the other side three weeks previously. In the previous anesthesia, she had presented normal mouth opening, and orotracheal intubation had been easily performed. Preoperative examination for the second surgery, however, revealed that she had a limited mouth opening with 1.8 cm of interincisor distance, resulting in a class 4 Mallampati view. A difficult airway was anticipated. In order to avoid the risk of hypertension caused by sedated-awake fiberoptic intubation, we planned orotracheal intubation under general anesthesia with AWS. After careful induction with fentanyl and propofol, the blade was inserted smoothly. Her glottic opening was easily visualized, and her trachea was intubated without any difficulty or any distinct hemodynamic disturbance. Careful assessment of the interincisor distance is essential in patients who have previously undergone craniotomy.

Lipocalin-type prostaglandin D synthase (beta-trace) in cerebrospinal fluid: a useful marker for the diagnosis of normal pressure hydrocephalus.

Lipocalin-type prostaglandin D synthase (PGDS) is considered to be mainly produced in the leptomeninges and secreted into cerebrospinal fluid (CSF). We found PGDS levels in CSF of patients with normal pressure hydrocephalus (NPH) (8.99+/-2.59 microg/ml, mean+/-S.D., n=14) to be significantly lower than levels in a control (15.29+/-5.17, n=14, P<0.0001) and other dementia group (19.14+/-4.34, n=7, P=0.0003). Thus, PGDS level in CSF is a useful marker for the differential diagnosis of NPH from other diseases with dementia.

Hemodynamic flow patterns evaluated by transcranial color-coded duplex sonography after STA-MCA bypass for internal carotid artery occlusion.

Extracranial-intracranial (EC-IC) bypass surgery had been widely performed for the treatment of internal carotid artery occlusion. However, it is presently difficult to predict how the bypass flow will contribute to intracranial circulation. We examined intracranial hemodynamics by transcranial color-coded duplex sonography (TCCD) after superficial temporal artery (STA)-middle cerebral artery (MCA) bypass and retrospectively studied the relationship between the postoperative contribution of the bypass flow and the preoperative collateral circulation and cerebrovascular perfusion status in 10 patients. Hemodynamics in the MCA detected by TCCD were classified into three patterns. In pattern A, perfusion of the whole MCA area is completely dependent on the bypass flow. In pattern B, perfusion of the M2 segment is dependent on the bypass flow, but perfusion of the M1 segment is independent of the bypass flow. In pattern C, perfusion of the whole MCA area is supplied by collateral flow and the bypass does not function efficiently. Preoperative absence of collateral flow via anterior communicating artery and cerebral perfusion status type 3 (reduced regional cerebral blood flow and regional cerebral vasoreactivity) seems to predict hemodynamic usefulness of the bypass flow after surgery. TCCD is an easy and noninvasive method for evaluating intracranial cerebral circulation after EC-IC bypass surgery.