Anatomical cerebellar protection of contrecoup hematoma development. Analysis of the mechanism of 30 posterior fossa coup hematomas.

The aim of this paper is to present the topographical/anatomical conditions that protect the posterior fossa from posterior fossa hematoma (PFH) resulting from contrecoup mechanisms and to point out the value of neuroradiological findings in determining force direction and transition. The biomechanism of this clinical entity also plays an important role in correct forensic interpretation. Generally, PFH are rare. In our series, they occurred exclusively as a result of forces applied to the occipital region. However, their appearance as a result of contrecoup mechanisms is exceptional. Considering the particular anatomical traits that protect the posterior fossa from the force transition of fronto-occipital (F-O) direction we put forth seven hypotheses which should explain the low incidence of PFH. Between 1989 and 1998, we treated 523 patients with intracranial hematomas caused by blunt trauma. Among them were 30 patients with PFH. All of them sustained an occipital bone fracture, confirming the coup lesion. In conclusion, it is difficult to determine clinically whether forces in the F-O direction could produce PFH as a result of contrecoup mechanism. That could be only proven in vivo by neuroradiological findings.

Intracranial infection after missile brain wound: 15 war cases.

OBJECTIVES: The present study describes 15 cases of intracranial infections developed in a group of in patients with missile brain wound (MBW), during the war in Croatia in the region of East Slavonia. METHOD: The retrospective study included 88 MBW casualties. There were 11 females and 77 males aged 2-80 years. The projectile penetration of the cranial dura was confirmed and the presence of intracranially retained foreign bodies was evaluated with computerized tomography (CT) in all the patients. The wounded were treated according to the modern recommendations of neurotrauma care. However, we extracted only accessible bone/metallic fragments during intracranial debridement. All intracranial infections were documented by cultures, CT, surgery or autopsy. The mean follow-up period of wounded with intracranial infections was 2.4 years (range, 10 days to 7 years). RESULTS: Intracranial infection developed in 14 patients (17%) as "early intracranial infections". Among 14/15 cases, infection developed within the first 8 weeks, and in 1 case 5 months after wounding. We recorded 4 cases of isolated bacterial meningitis, whereas in 9 cases brain abscess had developed. In 6 cases brain abscess was associated with concomitant meningitis and epidural empyema. Local cerebritis developed in one case, as well as subdural empyema with the concomitant meningitis in one case. There were 8 deaths in total of 15 cases. Glasgow Outcome Score 3 was observed in 2 and good outcome in 5/15 cases. The infectious organisms were isolated in 8 cases. Gram-positive bacteria were found in 12 different specimens. Gram-negative bacteria were found in 9 specimens. The most frequently isolated organism was Staphylococcus aureus. beta-hemolytic streptococcal and clostridial infections were not observed. Among the 15 patients with intracranial infection, just one did not have intracranially retained bone and/or metallic fragments. However, among the 73 head injuries without intracranial infections only 10 did not have retained fragments. CSF fistula and/or dehiscence developed in 13/15 patients with intracranial infection. In 67/73 wounded without intracranial infections, wound complications were not registered. CONCLUSIONS: The liberal use of post-contrast CT of the brain within the first 2 months after injury, especially if performed early in the clinical course, can lead to a prompt diagnosis of most of "early intracranial infections". The surgical procedures in order to prevent wound CSF fistula/dehiscence development are absolutely necessary. The immediate scalp and dural wound repair in case of wound complications are absolutely indicated and if needed, the procedures can be repeated. However, it seems that retained fragments are not responsible for an increased rate of intracranial infection.

Transoral missile removal from the anterior C1 region following transpharyngeal missile wound.

We present a successful treatment result in a rare case of low velocity missile transpharyngeal wound to the upper cervical area in a 33-year-old man. There are very few reports concerning related cases, with some disagreement regarding their treatment. The retained missile was successfully removed from the anterior region of the C1 vertebra through a transoral-transpharyngeal approach using the explosive transpharyngeal wound sustained. Neurological status and spine stability were not affected due to the missile's low velocity. The early soft-tissue debridement, missile removal, pharyngeal closure without wound drainage and broad-spectrum antibiotic coverage resulted in an uneventful postoperative course and good long-term outcome. Early surgery is important to prevent complications in such cases. However, the prophylactic tracheostomy, wound drainage and applying of a nasogastric tube could be left to the surgeon's judgment based on the individual patient's respiratory status, intraoperative findings and wound contamination/colonization.

Successful treatment of traumatic acute posterior fossa subdural hematoma: report of two cases.

BACKGROUND: Acute traumatic subdural hematoma of the posterior cranial fossa after a closed-head injury, excluding those in newborns, is a very rare clinical event. Generally, the outcome is poor and the overall mortality rate is high. METHODS: Acute posttraumatic subdural hematomas of the posterior fossa associated with acute hydrocephalus in two patients were removed by standard suboccipital approach. Preoperatively, one patient was in a coma and the Glasgow Coma Score was 9 in another. CT scans showed obliterated mesencephalic cisterns in both cases. In the former there was a complex posterior fossa lesion, i.e., combined subdural and intracerebellar hematoma. The surgical decompression was completed 3 and 11 hours after injury, respectively. Intraoperative tapping of the lateral ventricle through a burr hole in the occipital area was performed in the latter case. RESULTS: Both patients survived; one made a good recovery, (i.e., Glasgow Outcome Scale 4 in a patient who was comatose on admission), the other did not do as well (GOS 3). CONCLUSIONS: Our experience justifies the policy of mandatory early operation in cases of traumatic acute subdural hematoma of the posterior fossa associated with poor neurologic condition, even in patients of advanced age. In patients with obliterated mesencephalic cisterns and/or complex posterior fossa lesions the same approach must be followed. These clinical and CT features are not necessarily predictors of a poor outcome.

Skull osteolysis after mild head trauma: case report.

BACKGROUND: To our knowledge, there have been only two reported cases of patients with osteolytic skull lesions secondary to head trauma without concomitant skull fracture. METHODS: We present a case of skull bone lysis, not associated with skull fracture in a 20-year-old male, after mild head injury. During surgery, tumorous skull tissue of benign appearance was excised and primary cranioplasty was performed. RESULTS: The pathological examination showed an inflammatory reactive process within the bone lesion. Three years after surgery the patient was asymptomatic and studies did not show any new bone changes. CONCLUSIONS: The authors draw attention to this exceptionally rare condition, pointing out the necessity of surgical biopsy, contrary to some opinions.

Self-inflicted gunshot wounds to the head during the war and post-war period.

Thirty-five patients with self-inflicted gunshot brain injury were admitted to our hospital during 1991-96. War conditions and availability of firearms influenced the increase in these injuries, nearly six times greater than in the previous 6-year peace time period (1985-90). Our management protocol consisted of radical debridement of the missile track and evacuation of haematomata. For in-driven bone fragments we followed a less radical approach, but, if a post-operative computed tomogram (CT) showed a cluster of retained bone fragments, we operated on this. Attention was paid to the development of intracranial infection performing in such cases a contrast enhanced brain computed tomography. Ten patients died early and 29 were managed operatively. Twelve survived, and were followed-up for up to 60 months. No case of suicide recidivism was noted. We conclude that patients with a Glasgow Coma score of 3 should not be considered for operation. Per-operatively ultrasonography was very helpful in localizing and extracting in-driven bone fragments. Post-operatively, a CT scan is needed to demonstrate retained bone fragments.

Analysis of 127 war inflicted missile brain injuries sustained in north-eastern Croatia.

During the 4-year period (1991-1994) there were 127 consecutive patients with missile brain wound treated at the Division of Neurosurgery. They sustained brain injury in the region of east Slavonia, Baranya and north Bosnia, and were admitted mostly during the homeland defensive war in Croatia (1991-1992). Analysing the wounded, we divided them in two groups: "succumbed" (59 wounded) and "survivors" (68 wounded). We applied "less radical type of surgery", i.e. the patients were never re-operated only because of the retained single bone fragment. However, a retained cluster of bone fragments should be reoperated. The higher percentage of retained bone fragments (76.8%) is the result of precise visualization on the postoperative computed tomography (CT) scan. The last few cases have convinced us that the problem of the retained fragments could be solved by using an intraoprative ultrasonography. An intracranial (i.c.) infection (meningitis, abscess) occurred in 10 patients (10%), mostly among the patients who, besides the retained fragments, had cerebrospinal fluid (CSF) leak on the dehiscenced scalp wound. These cases should be reoperated soon after the CSF leak is visible on the dehiscenced wound. The overall mortality rate of 46.4% can be explained since our hospital was located close to the front-line, and some of severely wounded reached our hospital just in time to die. Excluding moribunds and those who died on the operating table (operated immediately after the admission), the mortality was 31.7%.

Spinous process-plasty following lumbar laminectomy as a contributing factor to spine stability.

A 10-year retrospective study of 41 consecutive patients who underwent "spinous process-plasty" is presented. We carried out laminectomy of the lumbar spine in cases of spinal stenosis, dorsomedial herniated disc and recurrent disc herniation with firm scars (traumatic and tumour cases are not included). To forestall the development of laminectomy's negative effects on spine stability, we initiated the spinous processes' reconstruction. Two groups of patients who underwent laminectomy form the basis of this presentation, one group with "spinous process-plasty" (41 patients) and the other (11 patients) without it. On postoperative neutral and dynamic X-ray films we paid attention to horizontal displacements larger than 3 mm and to negative intervertebral angular displacement. Considering such criteria, only 3.8% of those with "spinous process-plasty" developed a radiographic instability in contrast to 25% of patients without "spinous process-plasty". These results support the use of this technique, which provides postlaminectomy lumbar spine stability.

Management of missile wounds of the cerebral dura mater: experience with 69 cases.

Over the period of seven months: from July 1991 to January 1992 sixty-nine patients with penetrating head war-injuries, were admitted in our hospital. Missile wounds of the dura mater require in most cases urgent operative management: watertight closure of the dura defects. However, a dilemma still exists as to the best material to be used to restore the missile dural defects. There are several possibilities: an autologous substitute as periosteum (pericranium) from surrounding, fascia of the temporalis muscle, fascia lata, or allograft transplant as lyophilised cerebral dura mater (lyodura). In the group of 69 patients, 7 were treated conservatively, 13 were treated surgically, but without closing the dural wounds because of their critical condition, and in 45 surgically treated patients the dural defects were covered with 53 transplants: with periosteum in 22 patients but 24 coverings, with fascia of temporalis muscle in 2 patients, with lyodura in 6 patients, with fascia lata in 15 patients but 21 coverings. In 4 patients the dura wounds were sutured by interrupted sutures. The best results were obtained in the fascia lata group.