Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation: case report.

BACKGROUND: Vertebral artery injury during posterior C1-2 transarticular screw fixation occurs in approximately 3% of patients and may remain asymptomatic or result in arteriovenous fistulae, occlusion, narrowing, or dissection of the vertebral artery, and lead to transient ischemic attacks, stroke, or death. CASE DESCRIPTION: This is the first report of a pseudoaneurysm resulting from damage to the vertebral artery during the procedure. This 31-year-old male underwent posterior C1-2 transarticular screw fixation for unstable os odontoideum. Injury to the left vertebral artery occurred while the hole for the left screw was being drilled. Temporary control of bleeding with local pressure was followed by immediate postoperative angiography that revealed a left vertebral artery pseudoaneurysm. Although the patient remained asymptomatic, therapeutic anticoagulation was instituted 6 hours postoperatively. Increasing size of the pseudoaneurysm was noted on routine follow-up angiography 4 weeks later. Endovascular occlusion of the pseudoaneurysm and left vertebral artery, with preservation of vertebrobasilar flow through the right vertebral artery, was accomplished without neurological consequence. CONCLUSIONS: Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation may be effectively treated with endovascular approaches.

Nonoperative treatment of chronic subdural hematoma.

Chronic subdural hematomas that are asymptomatic or producing only mild symptoms are occasionally found with current neuroimaging methods. Some do not progress, and spontaneous resolution can occur. In addition, successful medical treatment of more significant hematomas has been reported. The indications for nonoperative management of these lesions are reviewed in this article.

The role of craniotomy and trephination in the treatment of chronic subdural hematoma.

The treatment of chronic subdural hematoma by craniotomy was the procedure of choice in the early part of this century. It has since been replaced by less invasive techniques but retains a limited role in the management of this condition. A new procedure involving a small craniectomy and marsupialization of the hematoma cavity to the temporalis muscle is described. The results of this treatment compare favorably with the more commonly performed drainage methods.

Prophylactic antibiotics with intracranial pressure monitors and external ventricular drains: a review of the evidence.

BACKGROUND: The role of prophylactic antibiotics (PABs) in preventing infections associated with intracranial pressure (ICP) monitors and external ventricular drains (EVD) is not well defined. METHODS: This study includes an analysis of published reports and a survey of current practices regarding the use of PABs with ICP monitors and EVDs. A computerized data search and a review of the abstracts from two major national neurosurgical meetings over the past decade yielded 85 related articles. Three independent investigators, blinded to the title, author(s), institution(s), results, and conclusions of the articles used predetermined inclusion criteria to select studies for meta-analysis. Thirty-six responses were returned from 98 questionnaires (37%) mailed to university neurosurgical programs. RESULTS: Among the articles reviewed, only two studies met the predetermined inclusion criteria for the meta-analysis, and they were of insufficient size to produce statistically significant results. Among the 36 programs that responded to the survey, 26 (72%) used PABs, mainly cephalosporins (46%) and semisynthetic penicillins (38%), with ICP monitors and EVDs. Twenty-two (85%) used one drug, and 4 (15%) used two drugs. Twenty-two (61%) of the total group reported intra-institutional variation in practices among individual staff neurosurgeons. Nineteen (53%) expressed interest in a retrospective study, and 27 (75%) expressed interest in a prospective study on the role of PABs in minor neurosurgical procedures. CONCLUSION: No consensus regarding the use of PABs with ICP monitors and EVDs is noted. Randomized controlled trials of sufficiently large size with appropriate blinding are needed to address this issue.

Giant intracranial and extracranial cavernous malformation. Case report.

Massive enlargement of an extracerebral cavernous malformation and extension across tissue planes is very uncommon. The authors present the case of a 49-year-old woman with a giant cavernous malformation in the left frontotemporal area. It progressively enlarged during several decades, extended through the calvaria to the extradural space, and was surgically treated. The lesion may have originated in the soft tissue or the skull. The locations of cavernous malformations in various parts of the body are reviewed and their mechanisms of growth are discussed. Surgical excision is the treatment of choice.

Entirely intracanalicular meningioma: contrast-enhanced MR findings in a rare entity.

We report an unusual case of an entirely intracanalicular meningioma in a 51-year-old woman. Contrast-enhanced MR images showed an enhancing lesion filling the lateral portion of the left internal auditory canal. Our findings suggest that meningiomas should be considered in the differential diagnosis of entirely intracanalicular masses.

Delayed deterioration after head trauma due to traumatic aneurysm.

Closed head trauma is fairly common in our industrialized society. A small percentage of affected patients develop traumatic intracranial aneurysms, which rupture an average of three weeks following injury resulting in sudden neurological deterioration. The case of a patient with a traumatic aneurysm is presented. A high index of suspicion is necessary to diagnose these lesions, for which surgical treatment is recommended.

Intraparenchymal hemorrhage.

Spontaneous hemorrhage into the cerebral parenchyma accounts for 8% to 13% of all strokes. It is more common in males, in blacks, and in the elderly. Fifty percent of cases are due to the effects of chronic hypertension on intracranial perforating arteries. The basal ganglia are the most frequent site of bleeding. Lobar hematomas tend to occur in younger patients, and may be due to specific causes such as vascular malformations. Many patients will have increased intracranial pressure and will require treatment in an intensive care unit. If surgery is necessary, stereotactic aspiration and pharmaceutical clot lysis are recent developments that may be advantageous. Prognosis is related to the patient's age and neurologic condition, and to the size, location, and rapidity of formation of the hematoma.

Giant cell tumor of the calvaria in a child. Case report.

A giant cell tumor involving the vertex of the skull is described in a 3-year-old child with no history of head trauma. The mass was present approximately 4 months prior to resection. Microscopically, the lesion consisted of highly cellular tissue composed of oval to spindle-shaped stromal cells admixed with numerous multinucleated giant cells. Giant cell tumor of the skull is a rare lesion, usually involving the sphenoid or temporal bone in adults. The differential diagnosis is discussed with reference to the literature regarding giant cell lesions, especially of the cranium. The authors are unaware of previous reports of a similar lesion in this location in such a young child.

Cranial epidural fibrous tumor associated with hyperostosis: a case report.

This report describes an unusual frontal epidural fibrous tumor in an adult woman. There had been no prior surgical procedure, radiation therapy, or significant head trauma. Microscopically, the lesion consisted of hypocellular, sparsely vascular, dense fibrous tissue. The fibrous mass was accompanied by hyperostosis of the frontal bone. The clinical and pathological characteristics of this lesion are illustrated. The differential diagnosis is discussed with reference to the literature regarding intracranial fibrous lesions. We are unaware of previous report of similar lesions in this location.

Indications for carotid endarterectomy.

Stroke is a major health problem in the United States. Carotid endarterectomy has been performed to prevent stroke in symptomatic and asymptomatic patients with carotid atherosclerosis. The rationale for this approach has been questioned recently and several studies were begun to determine the proper role of surgery. The initial results from studies of symptomatic patients demonstrate that surgery is urgently indicated if stenosis is at least 70%, but not if it is less than 30%. Patients with intermediate amounts of stenosis are still being evaluated. Early evidence suggests that surgery is not indicated for asymptomatic patients, but two major trials are still in progress. Surgeons performing this procedure must demonstrate low perioperative morbidity and mortality. In addition, the use of ultrasound as a screening procedure is being re-evaluated. We suggest rapid referral and evaluation of symptomatic patients with angiography, and treatment of asymptomatic patients with aspirin.

Clinical, radiographic, and pathological features of symptomatic Rathke's cleft cysts.

The clinical, radiographic, and pathological findings in 155 patients with symptomatic Rathke's cleft cysts are discussed. Eight patients were treated by the authors and 147 were collected in a review of the literature. This lesion occurred more often in female than male patients by a 2:1 margin, and the mean age at presentation was 38 years. The average patient had been symptomatic for nearly 3 years at the time of treatment, with the most common symptoms and signs being pituitary dysfunction, visual disturbances, and headaches. Affected children generally were pituitary dwarfs. The sella was enlarged in 80% of cases, and the cyst was situated in both an intrasellar and a suprasellar location in 71%. Computerized tomography revealed a low-density cystic mass with capsular enhancement in one-half of the cases. A variable appearance was seen with magnetic resonance imaging. Partial excision and drainage of the cyst by the transsphenoidal approach is the recommended treatment, as the recurrence rate is low. Most symptoms and signs improved or resolved following surgery with the exception of hypopituitarism and diabetes insipidus. The cyst lining was usually composed of ciliated cuboidal or columnar epithelium. Theories as to the origin of Rathke's cleft cysts are also discussed.

Subdural hematoma in the setting of internal carotid artery occlusion: CT studies.

A 72-year-old woman with previously symptomatic internal carotid artery occlusion subsequently presented with an acute hemispheric deficit. The patient was initially diagnosed as having an ischemic infarction but eventually was shown to have a subacute subdural hematoma with delay in surgical evacuation and a major permanent deficit. We speculate that internal carotid artery occlusion may predispose the patient to greater morbidity from subdural hematoma. Patchy hemispheric infarction may reflect greater vulnerability to extrinsic hemispheric compression in the setting of carotid occlusion. This case illustrates the necessity for vigorous pursuit of the diagnosis of subdural hematoma in patients presumed to have transient ischemic attacks or acute cerebral infarction.

Respiratory epithelial cyst of the cerebellopontine angle.

A case of a 29-year-old woman with a cystic lesion in the right cerebellopontine angle, who had three bouts of chemical meningitis in 1 year, is reported. The lesion proved to be a delicate, thin-walled cyst, in part with a squamous lining and in part with a respiratory epithelial (tall, columnar, ciliated, mucus-secreting) lining. Various possibilities to explain this unusual epithelium are explored.

Intramedullary spinal Histoplasma granuloma. Case report.

While there have been several cases of cerebral histoplasmoma published in the literature, the occurrence of such a lesion in an intramedullary spinal location has not previously been reported. The authors present a patient with a Brown-Séquard lesion secondary to an intramedullary Histoplasma granuloma in the cervical region. The case was successfully managed with surgical removal of the lesion.

Metrizamide-enhanced computed tomography as an adjunct to metrizamide myelography in the evaluation of lumbar disc herniation and spondylosis.

Eighty patients with operatively proven lumbar disc herniation or lumbar spondylosis were preoperatively evaluated with metrizamide myelography followed by metrizamide-enhanced computed tomography (CT). The x-ray films were reviewed without knowledge of the operative findings, and the patients were subdivided into those with disc extrusions, spondylosis, or recurrent abnormalities. For the group as a whole, CT was correct in 82% and myelography was correct in 77%. Both CT and myelography together were accurate in 91%, a significant improvement (P less than 0.02). The authors conclude that, if both studies are performed, the percentage of cases correctly diagnosed is increased. Therefore, both metrizamide myelography and metrizamide-enhanced CT should be obtained in selected cases. A review of the literature is included.