Management of a severe thoracoabdominal injury from motorized sawing machine in a temporary semi-urban university teaching hospital: a case report.

BACKGROUND: Report of our experience and outcome of a case of severe thoracoabdominal injuries by motorized sawing machine (a rare cause) in a Semi-Urban temporary University Teaching Hospital. METHOD: Literature review on the topic was done using Pubmed. Relevant journals and topics were also reviewed. Textbooks on relevant topics were also searched. RESULTS: A 25 year old male timber-cutter was traumatized by motorized sawing machine injuring the left half of the chest, upper abdomen, the left shoulder and left hand. It is an unusual presentation of penetrating thoracoabdominal injury. There was open pneumotharax, 3th-8th ribs fractures, diaphragmatic laceration, and eviscerations of abdominal contents without affecting other thoraco-abdominal organs. Urgent surgical intervention done was the only option. CONCLUSIONS: The challenges posed by severe motorized sawing machine thoraco-abdominal injuries in a Semi-Urban temporary University Teaching Hospital were successfully managed due to rapid pre-hospital transfer and co-ordinated team effort.

Anaesthetic Management for Surgical Relief of Neonatal Airway Obstruction Caused by a Cystic Hygroma

Background: Cystic hygroma is a rare congenital malformation of the lymphatic system which may cause neonatal airway obstruction. Surgical excision of this tumour is associated with high morbidity and mortality. Aim: To report the anaesthetic management for a successful excision of a cystic hygroma in a neonate. Case Report: A two-day-old female presented with history of an anterior neck swelling; tachypnoea and dyspnoea ; noticed at birth. There was associated stridor and subcostal recession. A diagnosis of cystic hygroma with upper airway obstruction was made. Tumour excision was done under endotracheal general anaesthesia. An intraoperative tracheostomy was carried out. Cyanosis occurred frequently within first 24 hours postoperatively while in the special care baby unit (SCBU) and was relieved by intermittent suction of the tracheostomy tube. Patient was weaned off the tracheostomy tube on the 30th post-operative day and discharged home two days later. She was subsequently followed up at the paediatric surgery outpatient clinic. Conclusion: Anaesthetic management for excision of a cystic hygroma in a neonate is by no means easy. It can be successful if the airway remains patent; ventilation is adequate; normothermia and optimal replacement of body fluid losses are ensured

Angiographic exclusion of intracranial arteriovenous malformations using onyx®.

Historically, endovascular treatment for cerebral arteriovenous malformations (AVMs) has been reserved as an adjunct to other modalities, namely radiosurgery and microsurgery, as the cure rate for cerebral AVMs treated solely with endovascular technique and older embolic agents is low. We report a series of five consecutive patients treated successfully with Onyx®, the newest available embolic agent, with resultant angiographic cure. Five patients aged three, nine, 33, 49, and 63 years were treated endovascularly for cerebral AVMs with a total of 19 embolizations with Onyx(®). All procedures were performed under general anesthesia with biplanar fluoroscopy. Complete angiographic obliteration of the AVM nidus was obtained in all cases with no residual filling. No immediate hemorrhagic or thromboembolic complications were observed. This early experience suggests that Onyx® has excellent embolization potential, and endovascular cure of AVMs may now be achieved with single modality therapy. Long terms data needs to be collected to further validate this observation.

Ruptured Giant Basilar Artery Aneurysm in a Comatose Adolescent: Successful Obliteration Using Intraoperative SSEP, BAER, and MEP Monitoring. A Case Report.

SUMMARY: Giant basilar aneurysms are infrequently seen in children. We present the endovascular management of an adolescent who presented comatose with pinpoint pupils due to a ruptured giant basilar trunk aneurysm. A noncontrast head CT disclosed a large prepontine lesion with brainstem hemorrhage. Catheter angiography showed a 4.5 cm irregular, fusiform basilar trunk aneurysm. With SSEP, BAER, and MEP monitoring, the patient underwent bilateral temporary vertebral artery occlusion, followed by GDC embolization of the aneurysm. Postprocedure internal carotid angiograms showed adequate blood supply to the basilar apex via patent posterior communicating arteries. On postprocedure day two, the patient was following commands. The remainder of his hospital course was uneventful. Postoperative angiograms showed no residual filling of the aneurysm. At 12 months the patient was neurologically intact and at baseline function as an honor student and follow-up angiogram showed persistent occlusion of the aneurysm from the circulation. Successful endovascular treatment has been considered a less invasive and safer alternative to surgical management of some complex vascular lesions. While most reports on reversing basilar artery flow have been carried out in awake patients with neurological examinations, this is not possible in a patient presenting in a comatose state. This report suggests that SSEPs, BAERs and MEP may be of use in such patients in safely carrying out basilar artery occlusion.

Ruptured intrasellar superior hypophyseal artery aneurysm presenting with pure subdural haematoma. Case report.

SUMMARY: Subdural haemorrhage from a ruptured intracranial aneurysm is a well-known entity when associated with subarachnoid haemorrhage. However, haemorrhage confined only to the subdural space is rare because there are limited anatomical sites where extravasation can be purely subdural. We report the rare case of a patient who suffered pure subdural haematoma after the rupture of a left superior hypophyseal artery aneurysm located within the sella turcica. The patient was treated with endovascular coil embolization of the aneurysm. Angiography immediately after treatment and one month later revealed complete obliteration of the aneurysm. Six months after treatment, the patient remained symptom free.

Laparoscopic anterior lumbar interbody fusion precipitating pituitary apoplexy.

OBJECTIVE: Pituitary apoplexy may be the first presentation of a previously undiagnosed pituitary adenoma. Although many mechanisms of pituitary apoplexy have been proposed in the literature, the exact pathogenesis remains unclear. Many predisposing events have been implicated in the pathogenesis, however, the role of laparoscopy precipitating pituitary apoplexy has not been previously described. The authors present a case of pituitary apoplexy in a previously undiagnosed pituitary adenoma, which presented in the immediate post-operative period after a laparoscopic anterior lumbar interbody fusion. CLINICAL PRESENTATION: A 45-year-old man presented with a sudden onset of headache, photophobia, diplopia, visual field deficits, and decreased visual acuity in the immediate post-operative period after an uneventful laparoscopic anterior lumbar interbody fusion. Results of computed tomography of the brain revealed a hyperdense suprasellar mass without any signs of subarachnoid blood. The patient underwent magnetic resonance imaging, which revealed a hemorrhagic pituitary tumor with lateral and suprasellar extension, with compression of the cavernous sinus and optic chiasm, respectively. An urgent transsphenoidal decompression of the hemorrhagic pituitary adenoma was performed. Post-operatively, the patient demonstrated marked neurological improvement with recovery of visual acuity and extraocular movements. CONCLUSION: To the authors' knowledge, this is the first case reported in the literature of a laparoscopic procedure precipitating pituitary apoplexy. Recognition of this rare complication of laparoscopic surgery, and the importance of rapid diagnosis and urgent surgical treatment are emphasized.

Approaches to the sellar and parasellar region: anatomic comparison of endonasal-transsphenoidal, sublabial-transsphenoidal, and transethmoidal approaches.

Various surgical approaches have been described for treating lesions which arise in the sellar region. The popular transnasal-transsphenoidal and transethmoidal-transsphenoidal approaches avoid the morbidity associated with transcranial operations while allowing enough exposure to successfully remove most lesions that arise in and around the sella. The goal of the present study was to accurately quantify the amount of exposure to the sellar and suprasellar region that the transethmoidal-transsphenoidal, endonasal-transphenoidal, and sublabial-transsphenoidal approaches provide. Each of the three approaches was performed on 14 formalin fixed heads with the aid of the operative microscope. The distances of relevant surgical landmarks, and the amount of exposure superior and anterior to the dorsum sella as well as the lateral exposure obtained through each of these approaches was carefully recorded. The mean distances were then used to calculate the volume of exposure offered by each approach. It was found that the sublabial-transsphenoidal approach afforded the greatest volume of exposure superior and anterior to the dorsum sella. The endonasal-transsphenoidal and the transethmoidal approaches were both found to offer less suprasellar volume exposure, with the transethmoidal approach offering the least. The authors believe the information obtained through this study illustrates some important anatomical relationships which can be used to advantage by the surgeon to tailor the most appropriate approach, depending upon the precise location of the lesion either within the sella or suprasellar region.