Neurosurgery
-
Diffuse arteriovenous malformations (AVM) have non-compact niduses, irregular margins, and intervening brain parenchyma. Deep perforating arteries often contribute to the ragged border of these diffuse AVMs. We hypothesized that diffuseness and deep perforator supply increase the difficulties and risks associated with microsurgical AVM resection. ⋯ Diffuseness and deep perforating artery supply are subtle features of an AVM that predict worse outcomes after microsurgical resection. Diffuseness makes surgical planes more difficult to determine and follow, whereas deep perforators are friable, poorly visualized, and located in eloquent white matter tracts. The Spetzler-Martin grading scale does not directly account for these two features; however, they should be considered carefully when making treatment recommendations to patients with AVMs.
-
The presence of a sellar macroadenoma with a concomitant tuberculum sellae meningioma typically requires a craniotomy for extirpation of the meningioma. We describe a single endoscopic approach for resection of both lesions. ⋯ With advances in endoscopic and image-guidance technology and increasing understanding of the endoscopic anatomy of the sellar region, surgeons are capable of reaching both intrasellar and suprasellar/anterior cranial base region tumors through a single endoscopic approach. The use of endoscopes in transsphenoidal approaches may obviate the need for additional craniotomies in properly selected patients.
-
Case Reports
Early hypodensity on computed tomographic scan of the brain in an accidental pediatric head injury.
Hypodensities on computed tomographic (CT) brain scans are thought to take at least 6 hours to become apparent after blunt head trauma. This finding, in conjunction with the later evolution of the hypodensities, is used in timing the injury in children with suspected non-accidental brain injury, in whom the history may be inaccurate. The purpose of this study is to report the occurrence of diffuse cerebral parenchymal hypodensities on CT scans performed within 5 hours of a well-defined accidental head injury. ⋯ It is unusual, but possible, to develop CT hypodensities as early as 1 hour after accidental head injury. In our small series of cerebral hemispheric hypodensity occurring less than 5 hours after trauma, all five patients had a uniformly fatal outcome. These observations may be important medicolegally in the assessment of the timing of head injury when the history of the trauma is not clear, as in children with suspected non-accidentally inflicted injury. It is inappropriate to generalize these findings to patients who are not unconscious immediately after a head injury, who regain consciousness after an injury before deteriorating, or who do not progress rapidly to brain death.
-
The use of dural sealants has become common in neurosurgery. Ten patients in whom a bovine albumin-glutaraldehyde combination (BioGlue; Cryolife, Inc., Kennesaw, GA) was implanted have had wound complications. The clinical experience of these patients is presented along with recommendations regarding the use of BioGlue. ⋯ We have found a strong association between the use of BioGlue and postoperative wound complications in our pediatric neurosurgical practice and, thus, discourage its future use. BioGlue triggers an intense acute pyogenic and chronic granulomatous inflammatory response, which is an ideal environment for bacterial growth. The bacteria may arise from the BioGlue or other foreign bodies or, more likely, from the skin if the inflammation breaches the skin surface.