Sinus pericranii associated with craniosynostosis.

Sinus pericranii is a vascular tumor of the head having communication with the dural venous system. The tumor enlarges with increased intracranial pressure when the patient is in the lateral recumbent position. Since Stromeyer used the term "sinus pericranii" in his report in 1850, approximately 170 cases have been reported. However, relatively few cases of sinus pericranii have been reported in association with craniosynostosis or by plastic surgeons. In this study, we report seven cases of sinus pericranii associated with craniosynostosis. There were two patients with Apert syndrome, two with Crouzon syndrome, two with oxycephaly, and one with trigonocephaly. The sites of occurrence were the parietal region in six patients and the frontal region in one patient. In either type of case, the tumor was clinically a soft subcutaneous mass of the head. The clinical characteristics of the tumor were its disappearance when the patient was in a sitting position and its appearance when the patient was in a recumbent position or crying. The patients were preoperatively diagnosed with sinus pericranii from imaging test findings, such as from magnetic resonance imaging and aforementioned clinical findings. In all cases, treatment for sinus pericranii was performed during the surgery for craniosynostosis. For patients with lesions in either site, we did not perform craniotomy, and we used a minimally invasive method of tumor excision and resection of the sites of communication using electrocoagulation. Perioperatively, heavy hemorrhage was not observed, and, postoperatively, no recurrence has been observed in any patient. In this study, we examine the etiology, diagnosis, and treatment of sinus pericranii, in particular for patients with craniosynostosis.

A reflectable case of obstructive sleep apnea in an infant with Crouzon syndrome.

Obstructive sleep apnea has recently drawn attention as a cause of sudden death among infants. Life-threatening obstruction of the upper airway is encountered in patients with syndromic craniosynostosis. Early definitive management of obstructive sleep apnea can conquer this critical situation. Although early tracheostomy can solve the problem, successful early midfacial distraction has been reported. In this report, a reflectable case of sudden death caused by a severe obstructive sleep apnea attack at home just before the midfacial distraction, during the waiting period for the surgery of midfacial distraction, is described. The authors stress the importance of preoperative care of the upper airway and the early definitive treatment using distraction osteogenesis for midfacial hypoplasia in infantile syndromic craniosynostosis.

Postoperative infection after duraplasty with expanded polytetrafluoroethylene sheet.

Dural reconstruction is a significant problem in many cases of decompressive craniotomy and dural defect. Expanded polytetrafluoroethylene (ePTFE) sheet have been used as a dura mater substitute for duraplasty. The outcomes of 83 consecutive patients at our institution were reviewed who underwent external decompression and closure with the ePTFE sheet between August 1995 and December 2000. Eight cases of infection occurred. Seven patients had infection with subdural empyema after cranioplasty with autologous bone. Three patients improved after removal of only the infected bone. One patient improved after removal of the infected bone and ePTFE sheet. One patient experienced wound infection after the original operation. Four patients subsequently developed local and severe inflammation with skin erythema until the ePTFE sheet was removed. Four patients had severe recurrent infections which required subsequent therapy such as vascularized free rectus abdominis muscle flap transfer. Duraplasty with ePTFE sheet might promote infection and poor circulation in the skin flap. The ePTFE sheet should be removed at an early stage in a patient with infection.

[Spontaneous epidural hematoma in a patient undergoing hemodialysis: a case report].

A 54-year-old male with chronic renal failure due to diabetic nephropathy suffered dysphagia and left facial spasm without head trauma during a hemodialysis session. CT scan revealed a right acute epidural hematoma. MRI and cerebral angiography did not reveal any abnormalities in the intracranial vasculature. The occurrence of intracranial spontaneous epidural hematoma in a haemodialysis patient has not been reported. During hemodialysis, the intracranial pressure transiently increases and rapidly recovers. It is assumed that the decreasing intracranial pressure caused epidural hematoma.

Three-dimensional cranial expansion using distraction osteogenesis for oxycephaly.

Oxycephaly is associated with raised intracranial pressure as a result of the fusion of multiple cranial sutures. We have performed an effective and less invasive cranial expansion by means of three-dimensional cranial distraction for the treatment of oxycephaly with suspicion of increased intracranial pressure. We describe two oxycephaly cases and the surgical technique of three-dimensional cranial expansion using distraction osteogenesis.

[Dissecting aneurysm of the middle cerebral artery with subarachnoid hemorrhage showing complete occlusion at the M2 portion of the middle cerebral artery on preoperative angiograms: case report].

We present a surgical case of a dissecting aneurysm of the middle cerebral artery associated with subarachnoid hemorrhage and intracranial hemorrhage. A 29-year-old man suddenly fell into a comatose state, and was referred to our hospital. CT scan showed diffuse subarachnoid hemorrhage and an intracerebral hematoma with marked midline shift located in the right frontal lobe. The right carotid angiogram revealed complete occlusion at the M2 portion of the middle cerebral artery, but failed to reveal any aneurysms in the rest of the intracranial circulation. We undertook emergent surgery to evacuate the hematoma and to confirm whether it was a dissecting aneurysm or not. After evacuation of the hematoma of the right frontal lobe, the Sylvian fissure was noticed to be widely opened. We detected a large dissecting aneurysm with a dark-purplish wall arising from the right M2 trunk, and we trapped the aneurysm. The postoperative course was uneventful and the patient gradually improved and was discharged without neurological deficits. We presented this case with a review of the literature.

[A case of cervical pyogenic spondylitis difficult to differentiate from metastatic spinal tumor].

A 52-year-old man with medical complications of diabetic mellitus and alcoholic liver dysfunction, presented with weakness in the bilateral lower extremities. Cervical magnetic resonance images disclosed the lesion extended from retropharyngeal space and multiple vertebral bodies to epidural space of the spinal canal, which was enhanced by gadolinium. Not only fever elevation during clinical course but also inflammatory reaction on selologic examination were not identified, so we initially thought the lesion metastatic spinal tumor. In researching original foci, his clinical condition worsened with gate disturbance and urinary incontinence. Eleven days later after admission, laminectomy from C-5 to Th-1 and open biopsy of the lesion was performed. The vertebral bodies exposed via the right frontal approach were covered by thick whitish membrane. Small mount of pus emerged after incision of the membrane, so we diagnosed the lesion pyogenic spondylitis. After the operation, high dose antibiotic therapy for 6 weeks was performed. Follow-up cervical MR imaging 4 months after the operation found that the volume of the lesion and compression of the spinal cord were reduced. The gate disturbance and urinary incontinence gradually improved, he was able to walk with a cane 6 months later.