The Relationships between Asterion, the Transverse-Sigmoid Junction, the Superior Nuchal Line and the Transverse Sinus in Thai Cadavers: Surgical Relevance.

Background: Anatomical localization of the venous sinuses in the posterior cranial fossa is important to preventing inadvertent venous sinus injury during surgical approaches to the area. Identification of surface landmarks related to these structures is useful in planning such approaches. Objective: To identify the positions of the asterion and the superior nuchal line for localization of the venous sinus in the posterior fossa. Material and Method: Twenty fresh cadaveric heads, yielding 40 sides, were used. The vessels were injected with colored silicone. The soft tissues were removed to expose the posterior cranium, from inion to the foramen magnum and laterally to the mastoid process. Using digital calipers, the relationship of asterion to the transverse-sigmoid sinus junction was determined and the distance from the highest superior nuchal line to the nearest transverse sinus was measured. Results: Asterion was located in 82.5% of the cadavers on the right side and 85.0% on the left side. The most common asterion position was at the junction of the transverse and sigmoid sinuses (67.5%), of which 5.0% were superior to the transverse-sigmoid junction, 2.5% inferior to the transverse-sigmoid junction and 7.5% medial to the transverse-sigmoid junction, at the transverse sinus. The superior nuchal line was identified in all cadavers. The most common position was inferior to the transverse sinus (60.0%) at an average distance of 8.55 mm 35.0% were at the same level as the transverse sinus and 5.0% were superior to the transverse sinus at an average distance of 2.14 mm. Conclusion: A burr hole inferior-medial to asterion can expose the posterior fossa dura with the least risk. The superior nuchal line is always identifiable and relatively close to the transverse sinus. A burr hole more than 3 mm inferior to the superior nuchal line can expose the posterior fossa dura with the least risk.

Citation Characteristics of Research Articles under the Center of Cleft Lip-Cleft Palate and Craniofacial Deformities, Khon Kaen University.

Center of Cleft Lip-Cleft Palate and Craniofacial Deformities, Khon Kaen University, has cooperated with the Medical Association of Thailand in publishing the special five issues of JMT (Journal of the Medical Association of Thailand) during the years 2010-2014 in order to promote research activities and working network of related fields in cleft lip-cleft palate and craniofacial deformities. This study aimed to examine the features of 106 research articles in terms of authors and disciplines, and analyze the citations considering sources, country and years after publication. The scope of study also included citations in the form of journal, which was presented as journal ranking compared with impact factors and Bradford's Law on journal citation. The results of study will be useful in developing multidisciplinary research activities of the center and especially assist in the acquisition of academic journals for essential sources of reference.

Incidence and variation of interpretably bone (os incae) in northeastern Thailand.

BACKGROUND: The squamous segment of occipital bone consists of cartilaginous and membranous origin. The cartilaginous part develops to supra-occipital bone. The membranous part has three primary ossification centers on each side. The first pair ossification center lies above the cartilaginous part between the superior nuchal line and the highest nuchal line and fuse with the cartilaginous part to form a supra-occipital segment of occipital bone. The second and third pairs have two nuclei each forming lateral and medial plates. All of these ossification centers fuse to form squamous segments of occipital bone. The fusion failure between ossification centers of second and third pair nuclei with each other or supra-occipital segment causes separated bone(s) called interparietal bone(s) or os incae. The interparietal bone should be differentiated from Wormian (intrasutural) bone. The incidence from various studies ranges from 0.37% to 9.50% of the population. OBJECTIVE: To study the incidence and variation of interparietal bone in Northeastern Thailand as compared with other studies. MATERIAL AND METHOD: A total of 400 Thai native skulls (276 male and 124 female) from the collection of Anatomical Museum of the Faculty of Medicine Khon Kaen University aged from 16 to 93 years old were examined by naked eye and photographed. Wormian bone was excluded by shape and site. The statistical method used was percentage of relative frequency. RESULTS: The incidence of interparietal bone in Northeastern Thailand is 7.25% (29 from 400). Males have a two times higher incidence rate than females, (8.33% versus 4.84%). Eleven patterns of interparietal bone were found. Fusion failure of a third pair ossification center is more common than second pair CONCLUSION: Knowledge of interparietal bone is useful for neurosurgeons and radiologists to avoid missed diagnosis of skull fracture. Presented interparietal bone may cause difficulty in surgery of occipital and parietal bone. Forensic scientist can use interparietal bone for personal identification.

Development of the acquisition model of online information resources at Faculty of Medicine Library, Khon Kaen University.

Faculty of Medicine Library, Khon Kaen University started to acquire online information resources since 2001 with the subscriptions to 2 databases. Nowadays it has 29 items of subscriptions and the expenses on online information resources reach to 17 million baht, more than 70 percent of the information resources budget, serving the academic purposes of the Faculty of Medicine. The problems of online information resources acquisition fall into 4 categories, and lead to 4 aspects conforming the model of the acquisition, comparing or benchmarking with the 4 selected medical school libraries in Bangkok, Chiang Mai, and Songkhla, and discussion with some other Thai and foreign libraries. The acquisition model of online information resources is developed from those problems and proposed for Faculty of Medicine Library, Khon Kaen University as well as for any medical libraries which prefer.

Supramastoid crest, safety landmark for craniotomy?

BACKGROUND: Bony landmarks are important in identifying and avoiding various structures, and thus, decreasing surgical morbidity. Knowledge of frontal bone was studied to help surgeons with safe craniotomy as temporooccipital region study was rare. OBJECTIVE: To identify usefulness of supramastoid crest and relationship to venous and Labbe's vein. MATERIAL AND METHOD: Twenty fresh cadaveric heads, the vessels were injected with colorized silicone, were studied on both sides, yielded 40 sides. The relationship of the supramastoid crest to the transverse, sigmoid sinus, Labbe's vein was also determined and measured. The following distances were measured utilizing the digital caliper for all measurements. RESULTS: Supramastoid crest was found in all cadavers (100%) and skull opened along supramastoid crest 100% safe from injury to venous sinus. Anterior border of supramastoid crest was close in relation to middle cranialfossa floor, 85% on right side and 90% on left side and the same level of middle cranial. The authors defined supramastoid point with turning of supramastoid crest and found distance from supramastoid point to nearest venous sinuse (always transverse sinus) 1.0-22.41 mm in range and average 12.94 mm on right side and 11.87 mm on left side. The last distance, from supramastoid point to nearest Labbe's vein, was measured and found to be 5.94-24.97 mm in range and average 17.23 mm on both sides. CONCLUSION: Supramastoid crest is bony landmark and easy to identify in the adult cadaver and craniotomy along supramastoid crest and always safe from injuring the venous sinus and Labbe s vein. 87.5% anterior border of supramastoid crest is the same level for middle cranial fossa floor.

Cerebral angiographic findings in patients with non-traumatic subarachnoid hemorrhage.

BACKGROUND: Even though ruptured intracranial aneurysm is a major cause of non-traumatic subarachnoid hemorrhage (SAH), non-aneurysmal SAH has a good prognosis with few neurologic complications. The gold standard for detecting the vascular pathology is digital subtraction cerebral angiography (DSA). OBJECTIVE: The primary objective of the present study was to clarify cerebral angiographic findings in patients with non-traumatic subarachnoid hemorrhage (SAH); to define the incidence of nonaneurysmal SAH. The secondary aim was to review the clinical data of all of the patients diagnosed with non-traumatic SAH in order to determine the associated etiology. MATERIAL AND METHOD: This retrospective, descriptive study, was conducted at Srinagarind Hospital, Faculty of Medicine, Khon Kaen University, between January 2005 and November 2010. The authors reviewed the medical records, cranial computed tomography (CT) and DSA of patients with non-traumatic SAH. The DSA findings were assessed and the correlation with clinical data and CT pattern determined. RESULTS: The author included and analyzed the records of 118 non-traumatic SAH patients (66 females, 52 males). The DSA discovered vascular lesions in 62.6% of cases (57.6% aneurysm, 4.2% arteriovenous malformation (AVM) and 0.8% Moyamoya disease). A total of 76 aneurysms were found in 68 cases. The location of the aneurysms included: 35.5% anterior communicating artery, 17.1% posterior communicating artery, 15.7% middle cerebral artery, 11.8% internal carotid artery 2.6% basilar artery, 1.3% vertebrobasillar junction and 10.5% others. The prevalence of nonaneurysmal SAH was 42.4% (50/118). In the multivariate analysis, hypertension was the factor most strongly associated with aneurysmal SAH on the DSA (p = 0.029). The location of SAH on Sylvian fissure was most frequently associated with the cause of aneurysms. In another way, tentorial cerebelli SAH was most commonly associated with a non-aneurysm cause. CONCLUSION: The present study revealed that the major cause of non-traumatic SAH is cerebral aneurysm. The factors associated with aneurysmal SAH included: hypertension and Sylvian fissure SAH. Tentorial cerebelli SAH was most commonly associated with a non-aneurysm cause.

Medical care for 4- to 5-year-olds with cleft lip/palate at the Tawanchai Center: geoinformatics study.

BACKGROUND: The incidence of cleft lip and cleft palate in Thailand is based on reports from three hospitals in Northeastern Thailand. There are 2.49 new babies born with cleft lip and cleft palate and craniofacial deformities for every 1,000 babies the highest incidence in the world. Area 7 Office of the National Health Security Office (NHSO) comprises Khon Kaen, Roi Et, Mahasarakam and Kalasin. The number of newborns with cleft lip and palate is an estimated 114 cases/year. A retrospective geoinformatics study was conducted using the medical records of 4- to 5-year-olds with cleft lip and cleft palate registered with the Tawanchai Center Srinagarind Hospital. OBJECTIVE: To study the distribution of 4- to 5-year-olds with cleft lip and palate using geoinformatics. MATERIAL AND METHOD: This retrospective study was conducted using data from the medical records, which contains the records of 4- to 5-year-olds with cleft lip and cleft palate admitted to Srinagarind Hospital. The 54-patient sample groups were registered at the Tawanchai Center Faculty of Medicine, Khon Kaen University, under the aegis of the NHSO (Area 7-Khon Kaen). The data were collected using self-administered questionnaires between May and June 2012 and geoinformatics, to study the distribution of patients' vis-a-vis the various parameters. RESULTS: Among the 27 male and 27femalepatients, 51.85% had cleft lip with cleft palate. Most of the cleft lip patients (7 cases; 41.18%) were in Khon Kaen, while 4 (44.44%) of the cleft palate patients were in Roi-Et and 11 (39.29%) of the cleft lip with palate patients were in Khon Kaen. Most cleft lip patients were in Roi-Et province: 1 case in each of four districts. Similarly, most cases of cleft palate were in Roi-Et province: 1 case in each of four districts. Finally, most cases (5; 50%) of cleft lip with cleft palate were found in Roi-Et province, mostly in the central (Muang) district. CONCLUSION: The use of Arc View software as an instrument for geoinformatics, spatial data collection helped to clarify the district level distribution of patients with CLP; this information is needed for policy planning and resource allocation.

Frontoethmoidal meningoencephalocele: challenges and the Tawanchai center's long-term integrated management.

BACKGROUND: The challenges for the management of patients with fronto-ethmoidal meningoencephalocele (FEEM) include: classification, assessment and analysis of the deformities, craniofacial reconstruction and long-term management. OBJECTIVE: To present experience of the Tawanchai Craniofacial Center of long-term integrated management and outcome of patients with FEEM. MATERIAL AND METHOD: Medical records were reviewed of 32 patients with FEEM treated by the authors between 1993 and 2011 at the Tawanchai Center, Srinagarind Hospital; the referral center for Northeast Thailand. RESULTS: Geographic Information System (GIS) analysis was used to examine the incidence and pattern of referrals to our Center. Most of the patients had the nasoethmoidal type (12 patients) followed by the combined naso-ethmoidal/-orbital type (8 patients). The surgical procedures included craniofacial reconstruction with medial canthopexy, orbital translocation, external repair and nasal reconstruction. Ultimately, most patients were satisfied with their remedied facial appearance. The Center's interdisciplinary protocol for the care of patients with FEEM was established. CONCLUSION: Experience demonstrated that a craniofacial center with interdisciplinary management was necessary to provide proper, early and longitudinal care and to achieve optimum outcomes for the patients with FEEM. In each case, the surgical outcome depended on the severity and classification of the deformities and the extent of associated brain anomalies. Nevertheless, in every case the final measurement should be done at the age of complete skeletal maturity. Funding from a number of sources, including the Foundation, is needed to ensure patients' access to treatment and follow-up and for the Craniofacial Cleft Center to improve the quality of treatment and programing.

Craniofacial surgery for craniosynostosis: challenges in diagnosis, management and long-term outcome.

BACKGROUND AND OBJECTIVE: Craniofacial surgery for craniosynostosis is one of the most challenging reconstructive procedures. Restoration of particular functional and anatomic requirements is important for development from infancy to adulthood. The purpose of this study is to present the authors' experience of craniofacial surgery for management of patients with craniosynostosis in Srinagarind Hospital, Khon Kaen, Thailand, addressing the challenges of diagnosis, management and outcomes, which may be adapted in other developing countries. MATERIAL AND METHOD: This paper presents the cranial and associated deformities, diagnosis, radiologic findings, preoperative evaluation, craniofacial and maxillary surgeries and outcome(s) of patients with craniosynostosis. The care team, made up of neurosurgeons, plastic surgeons, radiologists, ophthalmologists and pediatricians, established the Tawanchai Center's protocol for craniosynostosis, to manage the timing of craniofacial procedures from infancy to adulthood. RESULTS: The physical examination and radiologic findings of three patients, two with sagittal synostosis and one with plagiocephaly are reported. The clinical, craniofacial and maxillofacial surgeries and long-term outcomes of another three patients were studied one with Apert syndrome and two with Crouzon syndrome. All the latter three patients were lost to follow-up after the initial post-surgical visit. At that time, there were appropriate surgical results vis-a-vis appearance and satisfaction from the perspective of the two patients with Crouzon syndrome and their families. One of the patients with Crouzon syndrome received normal education supported by a successful family, while the other was still continuing her studies at school with good progress. The patient with Apert syndrome continued to live with his parents. Additional reconstructive surgery is recommended for all three patients. Economic problems and lack of adequate information were the main reasons for their discontinuing follow-up appointments. DISCUSSION AND CONCLUSION: Systematic physical examination and radiologic assessments by the craniofacial team are critically important for diagnosis, evaluation, planning of management and outcome assessment of the patients with craniosynostosis. In Thailand and other developing countries, the challenges in management of these patients are the development of standard craniofacial surgery, craniofacial team management and well-coordinated care, planned surgeries and outcome assessments from infancy to adolescence. A supportive government health system and establishment of a craniofacial center and foundation is needed in order to support and provide proper care for these groups of patients.