Remote cerebellar haemorrhage after lumbar spine surgery: case report.

Remote cerebellar haemorrhage (RCH) is a well-described complication of supratentorial surgical procedures with an incidence ranging between 0.2 and 4.9 %, but is a rare complication of spinal surgery. We report a case of RCH in a 65-year-old woman who showed sudden mental deterioration 48 h after lumbar spinal surgery, which was complicated by incidental dural tearing with minimal CSF loss. Brain CT scan revealed hypodense areas compatible with acute infarction involving mostly the left cerebellar hemisphere. No cerebral bleeding was observed. MRI was also performed revealing small cerebellar areas of acute infarction mainly relating the vermis and the left postero-inferior cerebellar hemisphere with haemorrhagic transformation and mass effect in the posterior fossa producing acute hydrocephalus. Haematoma removal was initially attempted by means of a suboccipital craniotomy. An external ventricular derivation was placed in a second procedure 24 h later due to the persistence of ventricular dilatation. At discharge the patient was only showing a slight dysmetria with the fine motor skills of hands and fingers. All cases of RCH after spinal surgery reported in the literature are invariably associated to iatrogenic dural tearing; although CSF loss seems to play the key role in the pathogenesis of this rare complication, the exact pathophysiology of this condition still remains undetermined.

[Results of various reconstructive procedures in defects of the fronto-facial area]. / Ergebnisse unterschiedlicher Rekonstruktionsverfahren bei Defekten im fronto-fazialen Bereich.

Small calvarial defects may be recontoured by Gore-Tex membranes or by micro burr hole covering plates in combination with bone dust. In extended defects the best primary and secondary results are obtained with splitted calvarium grafts due to their stabilizing and esthetic features. Micromeshes prevent contour disturbances in the contact zone of the transplants.

Transcapillary and interstitial diffusion of Na-fluorescein in chronic venous insufficiency with white atrophy.

White atrophy (atrophie blanche) in the medial ankle region due to chronic venous insufficiency (stasis syndrome) was studied in 12 patients by fluorescence video microscopy [1,8]. After intravenous bolus injection of 1 ml of 20% Na-fluorescein the dynamic phenomena of transcapillary and interstitial diffusion of the dye were analyzed by a videodensitometer which has moved on single frames of the TV-recordings across white atrophy at different times after dye appearance. White atrophy is characterized by 3 main areas: 1) the avascular field sensu strictu, 2) the border region with enlarged and tortuous capillary loops, and 3) the more remote capillaries showing less altered morphology. The dye reached the ankle skin after 39.2 +/- 13.3 S and leaved rapidly the intravascular compartment. In the region of the border capillaries, the maximal fluorescent light intensity was reached after 5 min, in the centre of the avascular field only after 40 min. Initially, the densitometer curves show a 'valley' which is slowly filled up by the dye. At 40 min and later on the highest light intensities were measured in the central parts of the avascular field ('mountain'), where the clearance was just beginning. The slow diffusion of the small tracer into the avascular field explains that white atrophy is a predilection site for venous ulcer formation.

Fluorescence microlymphography.

Microneedles, 0.2 mm o.d., were connected to a microsyringe and mounted on a micromanipulator. Under microscopic control, 0.01 ml of a 25% solution of FITC-labeled dextran-40 or dextran-150 were injected into the subepidermis at the big toe near the nailfold or in the medial ankle region. Fluorescence intravital microscopy revealed a network of lymphatic microvessels. The comparison with recent anatomic studies reveals that the reticular network visualized by FITC-dextran corresponds to the network in the stratum papillare. In 20 healthy subjects lymphatic capillaries were detected in a restricted area on the lateral aspect of the big toe. In 10 patients with primary lymphedema, the dye expanded to almost the entire dorsal skin surface of the big toe. In two cases, enlarged and tortuous microvessels of pathologic shape were observed. Fluorescence microlymphography is a simple and nearly atraumatic approach for depicting the intravital anatomy of human skin lymphatic capillaries.