Complex craniomaxillofacial gunshot wounds A step-by-step multidisciplinary approach.

BACKGROUND: Gunshot injuries of the viscerocranium are rarely reported. Penetrating wounds to the cranio-maxillofacial region pose a significant challenge for surgeons as they often comprise serious soft tissue, bone and cerebral defects. We present a case report of a 42-year old female with a gunshot wound to the viscerocranium after suicidal attempt. Series of image of the disease course are available. CASE DESCRIPTION: A 42-year-old female presented with gunshot wound to the viscerocranium after a suicidal attempt. At the arrival GCS was 8/15 and general examination showed the inlet wound in the submental region whereas the outlet one in the left temporal skull area. After first rescue procedures, ICP was monitored before proceeding surgically. Due to massive hemorrhage, embolization of ianternal maxillary artery was performed. Afterwards, tracheostomy, surgical reduction of multiple maxillo-facial fractures and ocular avulsion were performed. In a second time, ICP monitoring and CT scan revealed ICH signs due to intraparenchimal injures. The patient underwent to a second surgical procedure, consisting of bifrontal decompressive craniectomy. The patient was discharged on 20th post-op day to a rehabilitation center. She returned to our department after 4 months to perform a craniomaxillofacial recostruction. She presented 15 in GCS, left ptosis, left VII cranial nerve deficit, decannulated, KPS 100%. CONCLUSION: A step-to-step multidisciplinary approach both with Neurosurgeons and Maxillo-facial surgeons is mandatory in Cranial Gunshot Injuries where extensive damage is linked to a higher mortality. KEY WORDS: Cranial gunshot inuuries, Cranial reconstruction, Maxillofacial reconstruction.

Multiple simultaneous intracerebral hemorrhages: Clinical presentations and risk factors.

OBJECTIVE: Multiple simultaneous intracerebral hemorrhages (MSICH) are a rare clinical entity. The mechanism and risk factors have yet to be elucidated. The purpose of this study was to clarify clinical presentations and risk factors of MSICH compared with solitary intracerebral hemorrhages (ICH). PATIENTS AND METHODS: Medical records of 313 consecutive patients with ICH admitted to our institution between April 2011 and September 2014 were retrospectively reviewed. Seventeen cases of MSICH were identified, and 10 clinical and neuroimaging variables were compared between MSICH cases and solitary ICH cases using the unpaired t-test, chi-square test, and multiple logistic regression analysis. RESULTS: There were significant differences in size between larger hematomas (mean 59.2±69.1mL) and smaller hematomas (mean 1.7±2.1mL) in patients with MSICH (p=0.001). Larger hematoma volume was the only independent risk factor for MSICH in multiple logistic regression analysis (OR=1.012, 95%CI 1.004-1.021, p=0.004). CONCLUSIONS: Patients with MSICH have clinical characteristics and outcomes similar to patients with solitary ICH. They present with two significantly different hematoma sizes, both of which are significantly larger than patients with solitary ICH, suggesting that a larger hematoma can trigger smaller hematomas. A future prospective study with a larger number of patients will explore the precise mechanism of this rare entity.

Three-dimensional microsurgical anatomy of cerebellar peduncles.

The microsurgical anatomy of cerebellar peduncles and their relationships with neighbouring fasciculi were investigated by using a fibre dissection technique. As the dissection progressed, photographs of each progressive layer were obtained and stereoscopic images were created using the 3D anaglyphic method. These findings provided the anatomical basis for a conceptual division of cerebellar peduncles into segments. The middle cerebellar peduncle (MCP) was divided into two segments: cisternal and intracerebellar segments. The inferior cerebellar peduncle (ICP) was divided into three segments: cisternal, ventricular and intracerebellar segments. The superior cerebellar peduncle (SCP) was divided into three segments: intracerebellar, intermediate and intrategmental segments. The fibre dissection technique disclosed a constant course of peduncular fibres inside the white core of the cerebellum. The pontocerebellar fibres of the MCP pass over and laterally to the bundles of the ICP and SCP. The centripetal fibres of the ICP wrap around the radiation of the SCP and the dentate nucleus, directed towards the cortex of the vermis. The centrifugal bundle of the SCP ascends towards the mesencephalon where it sinks passing below the fibres the lateral lemniscus. The knowledge gained by studying the intrinsic anatomy of the cerebellum is useful to accomplish appropriate surgical planning and, ultimately, to understand the repercussions of surgical procedures on the white matter tracts in this region.

Primary dumbbell-shaped lymphoma of the thoracic spine: a case report.

Primary spinal non-Hodgkin's lymphoma is extremely rare, and the occurrence of spinal dumbbell-shaped lymphoma is exceptional. We present a case of primary spinal dumbbell-shaped lymphoma to clarify the diagnosis and the management of these lesions. A 45-year-old man presented with sensory symptoms for 8 months. Magnetic resonance imaging of the thoracic spine demonstrated a dumbbell-shaped lesion at the D4-D6 level with spinal cord compression and right foraminal extension at D4-D5 level. The patient underwent D4-D6 laminectomy, with a subtotal resection of the mass. Diffuse large B-cell lymphoma was diagnosed in the pathological examination. He underwent local spinal radiotherapy and chemotherapy. Follow-up evaluation at one year demonstrated no evidence of relapse. Although highly unusual, lymphoma should be included in the differential diagnosis for spinal dumbbell-shaped tumours. After surgery and adjuvant therapy a long-term clinical and neuroradiological followup is mandatory.

Thoracic extradural haematoma after epidural anaesthesia.

The administration of analgesics to the thoracic spine is established practice in the operating room, minimizing the need for systemic anaesthetic administration during thoracic surgery. Complications arising from thoracic epidural anaesthesia are uncommon but potentially disastrous. Here, we report the case of a 43-year-old woman who developed a thoracic epidural haematoma with paraplegia a few hours after the removal of an epidural catheter. The patient underwent emergency thoracic laminectomy and clot evacuation. After a 4 months period, there was almost complete neurological recovery. Epidural haematoma is a rare complication that must be heeded and urgently treated in case of clinical deterioration after the epidural analgesia.