Ectopic extraspinal meningioma: CT and MR appearance.

We report a case of an ectopic, extraspinal meningioma that appeared as a midline interscapular mass in a 13-year-old girl. The tumor involved the T-2 and T-3 spinous processes, but was dorsal to the lamina and was entirely extrinsic to the spinal canal. Large amounts of tumoral calcification and reactive hyperostosis were present, radiologically mimicking an osteogenic sarcoma.

The effect of fiberoptic bronchoscopy on cerebral hemodynamics in patients with severe head injury.

STUDY OBJECTIVE: Concerns exist about the effect of flexible fiberoptic bronchoscopy (FFB) on intracranial pressure (ICP). We studied the effect of FFB on cerebral hemodynamics in patients with severe head injury. DESIGN: Prior to FFB, patients were anesthetized and muscle relaxants were given as necessary to eliminate coughing. Comparisons were made of mean arterial pressure (MAP), ICP, and cerebral perfusion pressure (CPP) prior to, during, and after FFB, as well as comparisons of mean cerebral hemodynamic values in an 8-hour period before and after FFB. Observations were made of changes in neurologic status post-FFB. SETTING: Surgical intensive care unit of Level 1 Trauma Center. PATIENT POPULATION: Fifteen patients with severe head injury in whom ICP was monitored and who required FFB for diagnosis of nosocomial pneumonia or treatment of lobar collapse. RESULTS: Pre-FFB ICP averaged 14.3 mm Hg (range, 6 to 26 mm Hg). During FFB, patients experienced a mean increase in ICP of 13.5 mm Hg above basal values (p = 0.0001). At peak ICP, MAP increased from a baseline of 92.3 mm Hg (SD +/- 16.1) to 111.5 mm Hg (+/- 13.9). Mean CPP was 83.7 mm Hg at peak ICP (range, 52 to 121 mm Hg), a 14.0% increase over baseline. The ICP and MAP returned to basal levels following bronchoscopy. No patient had a clinically significant increase in ICP or demonstrated any deterioration in Glasgow Coma Scale score or neurologic examination findings post-FFB. CONCLUSIONS: Although FFB causes an increase in ICP in patients with severe head injury, MAP also rises, and an adequate CPP is maintained. The ICP returns to basal levels after the procedure. When properly performed, FFB does not adversely affect neurologic status in patients with severe head injury.

Anterior stabilization of thoracolumbar burst fractures using the Kaneda device: a preliminary report.

Anterior decompression and fusion is a valuable technique in the treatment of thoracolumbar burst fractures. Anterior instrumentation has evolved to correct deformity and stabilize the spinal segments during decompression and bone grafting as a single-stage procedure. One anterior device developed by Kaneda has been used in our institution since 1989. This study is an initial review of our experience with this instrumentation. Anterior decompression and fusion augmented with the Kaneda device was performed in 20 patients with thoracolumbar burst fractures. Timing of surgery was early (< 15 days) in 13 patients, intermediate (16 to 120 days) in 2, and delayed (> 121 days) in 5. Sixteen patients were neurologically intact (Eismont grade D), 3 with distal weakness (Eismont grade B or C) and 1 with complete paraplegia (Eismont grade A). All patients with deficits recovered one Eismont grade after anterior decompression and fusion. Complications included pulmonary problems in 2 patients, a thoracic duct laceration requiring ligation, and a sympathectomy effect of the lower extremity. One patient had a pulmonary embolus and developed a hematoma at the graft harvest site while on anticoagulants with resultant meralgia paresthetica. There have been three screw failures and one definite pseudarthrosis. Anterior decompression and fusion supplemented by the Kaneda device was performed on 20 patients with thoracolumbar burst fractures. The average correction of kyphosis was approximately 50% acutely, with loss of approximately 50% of correction at follow up. In some patients, coronal plane deformity was created by the device. No effect on neurologic recovery could be shown with this small series. Perioperative complication rate was 30%, and 1 patient developed pseudarthrosis.

Cranial fractures associated with facial fractures: a review of mechanism, type, and severity of injury.

A 100-month retrospective review was undertaken to identify the population characteristics of patients with both facial and cranial fractures and to establish the relationships between them. A 4.4% incidence of cranial fractures was found in the 882 patients with facial fractures. These patients tended to be males (85%) between the ages of 16 and 30 years (54%) who were involved in motor vehicle accidents (64%). Patients with midfacial fractures predominated (70%), and these injuries were most frequently associated with fractures of the frontal (38%), sphenoid (24%), or temporal (22%) bones. No relationship was noted between mandibular fractures and cranial fractures. Midfacial fractures were related to individual cranial bone fractures by sutural attachment. The presence of cranial fractures did not play a role in the development of complications associated with facial fractures.

Management of closed head injury in the patient with maxillofacial trauma.

Closed head injury (CHI) affects approximately one in five patients who sustain facial fractures. The effects can range from simple loss of consciousness to coma and death. The high incidence of CHI in the facial trauma population and the potential for mortality and neurologic morbidity make it a distinct concern of the practicing oral and maxillofacial surgeon. This article discusses the evaluation, monitoring, and management of CHI and includes special consideration of the treatment of maxillofacial injuries in these patients.

Transient neurologic deficit caused by chronic subdural hematoma.

Transient neurologic deficits are an unusual presentation of chronic subdural hematoma. Presented herein are three patients with transient aphasia and right-sided sensory-motor abnormalities caused by subdural hematoma. Review of the literature revealed 32 cases similar to ours. Presenting complaints were aphasia (77%), sensory symptoms (57%), headache (48%), hemiparesis (50%), and visual disturbance (3%). Fifteen patients underwent cerebral angiography; only three showed significant carotid atherosclerosis. Electroencephalograms were performed in seven patients; five revealed lateralized slowing, but none showed epileptiform activity. Drainage of the hematoma was uniformly curative, although six patients had transient postoperative symptoms. Patients presenting with transient deficits require imaging to rule out the presence of a chronic subdural hematoma.

A review of 100 closed head injuries associated with facial fractures.

One hundred closed head injuries associated with facial fractures treated over a 78-month period at a level I trauma center in Northeast Ohio were reviewed. The incidence of closed head injury in patients with facial fractures was 17.5%. Males suffered closed head injuries four times more often than females, and sustained severe intracranial injuries eight times as often. The 16- to 30-year age group predominated (59%). Although motor vehicle accidents were the most frequent cause of injury (61%), motorcycle accidents were associated with the most severe head injury. The mandible/midface fracture ratio (1.3:1) was almost half that of the non-head-injured population (2.1:1). Facial fracture complications were found to have a similar incidence (14%) as in the non-head-injured population, but were associated with more severe intracranial injuries.

Disc herniation in cervical fracture subluxation.

Previous reports of computed tomographic scan with contrast myelography in cervical spinal cord injury have shown a rate of disc herniation of less than 5%. We hypothesized that injuries associated with forces adequate to cause bone or ligamentous injury in the region of the disc space could be associated with higher and more significant rates of disc herniation. Thirty-seven consecutive traumatic midcervical fracture subluxations were reviewed. Fracture subluxation was defined by fracture of the facet joints, pedicles, or vertebral bodies or more than 3.5 mm subluxation from C2-C3 to C7-T1. Reduction was achieved in 97% and was not associated with neurological deterioration. On the basis of plain films, tomograms, and plain computed tomographic scans, the injuries were classified as flexion dislocation, flexion compression, compression burst, or extension injuries. Twenty-five computed tomographic scans with contrast myelograms and one magnetic resonance imaging scan were obtained. All patients with partial neurological deficits were studied. A herniated disc was defined as that which deformed the thecal sac and/or nerve roots. Retrospectively, a neuroradiologist reviewed the studies for the presence of herniated disc. Disc herniation was seen at the level of injury in 9 (35%) patients and not seen in other patients. Forty-seven percent of the patients with partial deficits had herniated discs. Herniated disc was seen most frequently in flexion dislocation and flexion compression injuries. Three patients (20%) with partial deficits underwent discectomy. Patients with partial spinal cord injury and discectomy, on average, improved more than other patients with partial spinal cord injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical spine fractures and maxillofacial trauma.

Cervical spine fractures are a serious complication of maxillofacial trauma because of the high potential for mortality and neurologic morbidity. This study reviewed 563 patients with facial fractures treated by the Division of Oral and Maxillofacial Surgery at a level I trauma center and identified 11 concomitant cervical spine fractures (2.0%). These patients were almost exclusively male (91%), white (100%), between 20 and 35 years of age (64%), involved in a motor vehicle accident (91%), with a concomitant mandibular fracture (91%). The examination, diagnosis, and management of patients with cervical spine injuries are discussed.

Immunohistochemical recognition of ethylnitrosourea induced rat brain microtumors by anti-Leu 7 monoclonal antibody.

This immunocytochemical study was undertaken to clarify the histogenesis of ethylnitrosourea-induced rat brain tumors. The tumors induced in offspring of Sprague-Dawley rats injected with ethylnitrosourea on day 18 of gestation were used in these experiments. Controls consisted of pregnant Sprague-Dawley rats similarly injected with saline alone. Both microtumors (less than 1 mm) and macrotumors were examined immunocytochemically. The cells present in both macro- and microtumors were reactive with anti-Leu 7, an antibody which recognizes oligodendrocytes. Intermixed with, but distinct from the tumor cells were glial fibrillary acidic protein positive cells morphologically identical to astrocytes found in other areas distant to tumors in the treated animals, and in controls. These data suggest that both early and late tumors are oligodendrogliomas, not astrocytomas or mixed gliomas, and that the cell of origin of the tumor is the oligodendrocyte rather than an uncommitted stem cell as previously suggested.

Tropomyosin isoform expression in normal and neoplastic astrocytes.

Changes of tropomyosin isoforms have previously been found accompanying morphologic alterations such as those associated with neoplastic transformations in mammalian cells. To determine whether an isoform change is associated with the malignancy of brain tumors, we employed both polyclonal antibodies specific to high and low molecular weight tropomyosin isoforms. We found, by using immunocytochemistry and immunoblotting, that an alteration of tropomyosin isoforms is associated with human astrocytomas. Differential staining patterns were seen for normal, reactive, and neoplastic astrocytes. Characterization of the antibodies revealed an increase in the higher molecular weight tropomyosin in more anaplastic astrocytomas than in those that were well differentiated. We also observed that the different isoforms have specific subcellular localizations. These findings suggest that neoplastic transformation is associated with alteration of tropomyosin isoforms in astrocytomas. We speculate that this change may be related to morphologic transformation in which microfilament functions, such as cell shape, interaction, and recognition are altered.

Ubiquitin in normal, reactive and neoplastic human astrocytes.

Ubiquitin, a protein important in regulating non-lysosomal proteolysis, has previously been shown to be present in cytoskeletal inclusions of the neurodegenerative diseases. Its role in other pathological processes of the central nervous system, such as neoplastic transformation of cells, is not known. The astrocytoma, a tumor of complex biology derived from the astrocyte, is the most common primary parenchymal human brain tumor in both children and adults. Until recently, ubiquitin was not known to form stable conjugates in cells. We have shown using immunocytochemistry on sections of astrocytomas that both glial fibrillary acidic protein (GFAP) (the major intermediate filament protein present in normal, reactive and neoplastic astrocytes) and ubiquitin are simultaneously present in the cytoplasm and cell processes of tumor cells. The presence of ubiquitin and GFAP was also found in astrocytoma cells in short- and long-term culture, and confirmed by immunostaining of blots of tumor homogenates subjected to sodium dodecyl sulfate polyacrylamide gel electrophoresis.

Branhamella catarrhalis cellulitis around a cerebrospinal fluid shunt: case report.

A cellulitis surrounding a cerebrospinal fluid shunt caused by Branhamella catarrhalis is described. This is the first reported case of a cellulitis caused by this bacterium.

Atlantoaxial rotatory subluxation, congenital absence of the posterior arch of the atlas, and cerebral palsy: an unusual triad.

Posttraumatic chronic atlantoaxial rotatory subluxation and congenital absence of the posterior arch of the atlas are rare upper cervical spine abnormalities. The present case is that of a 4-year-old girl who had these two spinal disorders as well as spastic cerebral palsy. The interrelationship, if any, between these three conditions is unclear but presented an unusual diagnostic triad. A posterior spinal fusion between the occiput and third cervical vertebra was performed because of concern for upper cervical spine instability. The patient was immobilized in a halo vest, and a solid fusion occurred within 3 months. Preoperatively the child had never walked independently, but postoperatively, while wearing the halo vest, she was able to walk without external support, thus raising the suspicion of previous spinal instability. Fifteen months postoperatively she remains spastic but has a stable, orthotic-free, independent gait.

A high performance isolated rat brain preparation. Part I: Operative technique and recipient extracorporeal perfusion.

The microsurgical preparation and high level performance with extracorporeal recipient perfusion of a stable, totally isolated rat brain model is presented. Emphasis has been placed on the use of the operating microscope, bipolar cautery and mechanical fixation units to affect a complete ablation of all non-osseous cephalic and vertebral tissues with minimal physiological disturbance of the animal as a whole. The simplified technique of recipient support circulation of the isolated brain organ achieves at least 5 h of tissue viability and function as measured by electrocortical activity, A-Vo2 differences and morphological appearance. To date, no other isolated rodent brain model has been described which is truly anatomically separated from all cephalic tissues. Additionally, other surgical attempts at isolation have required the use of abnormal physiological states, including deep hypothermia and circulatory arrest.

A high performance isolated rat brain preparation. Part II. Cerebral blood flow in relation to perfusion pressure and cerebral hypothermia.

The effects of changes of perfusion pressure and hypothermia on the cerebral blood flow of a new isolated rat brain preparation have been studied in 7 animals. The cerebral blood flow was extremely sensitive to the mean arterial pressure of perfusion, showing little evidence of autoregulation at low pressure, and only slight evidence in hypertension. The cerebral blood flow was lower in hypothermia. The preparation maintained good electroencephalographic activity throughout, and arteriovenous differences persisted up to 1 h after it became isoelectric.