Cerebral Fat Embolism: Clinical Presentation, Diagnostic Steps and Long-Term Follow-Up.

OBJECTIVE: Symptomatic cerebral fat embolism (CFE) is a rare complication that occurs after a traumatic injury or orthopaedic surgery and is diagnostically challenging. No data is currently available concerning long-term follow-up. METHODS: We identified from medical records 9 patients with CFE and revised the clinical signs and the diagnostic process. We then analysed long-term follow-up data, targeting clinical course after discharge, neurological impairment, and current quality of life, using the Barthel index and the modified Rankin Scale. RESULTS: All 9 patients initially showed severe neurological deficits, including disturbance of consciousness ranging from somnolence to coma. During the follow-up period for 3-58 months after the insult 2 patients had died. The 7 patients who remained alive had either recovered completely or showed only minor neurological deficits after rehabilitation. They were nearly independent in daily life and needed only minimal assistance. We performed the first brain biopsy in a patient with CFE. CONCLUSION: Most patients had a good outcome after long-term follow-up. In patients with an unexplained altered state of consciousness after a traumatic injury or an orthopaedic surgery, an MRI with diffusion-weighted imaging must be performed to uncover the characteristic pattern of disseminated hyperintense lesions in the white matter that are associated with CFE.

Clinical value of endosonography in the assessment of laryngeal cancer.

BACKGROUND: Endosonography has been successfully used in staging gastrointestinal cancer, but its value is as yet undetermined in laryngology. METHODS: This prospective study includes 84 patients undergoing microlaryngoscopy for laryngeal cancer. The results of endosonography were compared with those of CT and MRI in the 76 surgical cases. RESULTS: In the assessment of laryngal cancer, endosonography was superior to current imaging techniques, whereas CT and MRI showed similar results (accuracy of 89% vs 77% and 77%, respectively). CONCLUSIONS: This study confirms that endosonography is highly effective in staging laryngeal cancer. Therefore, the latter may constitute a complementary diagnostic tool in these tumors and additionally may assist in choosing an adequate treatment.

Early decompressive craniectomy and duraplasty for refractory intracranial hypertension in children: results of a pilot study.

INTRODUCTION: Severe traumatic brain injury (TBI) in childhood is associated with a high mortality and morbidity. Decompressive craniectomy has regained therapeutic interest during past years; however, treatment guidelines consider it a last resort treatment strategy for use only after failure of conservative therapy. PATIENTS: We report on the clinical course of six children treated with decompressive craniectomy after TBI at a pediatric intensive care unit. The standard protocol of intensive care treatment included continuous intracranial pressure (ICP) monitoring, sedation and muscle relaxation, normothermia, mild hyperventilation and catecholamines to maintain an adequate cerebral perfusion pressure. Decompressive craniectomy including dura opening was initiated in cases of a sustained increase in ICP > 20 mmHg for > 30 min despite maximally intensified conservative therapy (optimized sedation and ventilation, barbiturates or mannitol). RESULTS: In all cases, the ICP normalized immediately after craniectomy. At discharge, three children were without disability, two children had a mild arm-focused hemiparesis (one with a verbal impairment), and one child had a spastic hemiparesis and verbal impairment. This spastic hemiparesis improved within 6 months follow-up (no motor deficit, increased muscle tone), and all others remained unchanged. CONCLUSION: These observational pilot data indicate feasibility and efficacy of decompressive craniectomy in malignant ICP rise secondary to TBI. Further controlled trials are necessary to evaluate the indication and standardization of early decompressive craniectomy as a 'second tier' standard therapy in pediatric severe head injury.

Intracranial venous hemodynamics is a factor related to a favorable outcome in cerebral venous thrombosis.

BACKGROUND: In recent studies, coma, cerebral hemorrhage, older age, and infectious origin have been identified as prognostic factors in cerebral venous thrombosis (CVT). However, no studies of the prognosis of CVT have evaluated hemodynamic factors. However, it is conceivable that the presence or absence and the efficiency of venous collaterals, as well as recanalization, may have an impact on brain tissue damage and hence on the prognosis of acute CVT. METHODS: Twenty-six patients with acute CVT (mean age, 40+/-15 years) were recruited prospectively. All patients were treated with intravenous heparin, followed by oral anticoagulation for 12 months, except for 2 patients who were lost to follow-up after hospital discharge. Neurological deficits were graded on the National Institute of Health Stroke Scale on admission, at hospital discharge, and at 90+/-14 days after admission. The functional clinical outcome was graded on the modified Rankin Scale on day 90 after admission. All patients received a venous transcranial duplex sonography (TCCS) on admission and were followed up in case of a pathological result until normalization was recorded (mean follow-up, 316+/-395 days; range, 13 to 1180 days). RESULTS: Initial TCCS was pathological in 18 of 26 patients (69%). Four distinct venous drainage types were identified: increased drainage to the cavernous sinus and to the deep cerebral veins, flow reversal in the basal veins, and either compensatory increased or reversed flow in the transverse sinus. Initially normal venous TCCS or normalized TCCS within 90 days was significantly related to favorable outcome. CONCLUSIONS: TCCS can be used to evaluate venous drainage patterns in acute CVT. Furthermore, initially normal and normalization of initially pathological venous TCCS within 90 days is related to a favorable outcome in this disease.