Skull fracture after a head injury is relatively common in children younger than 2 years of age. The author reports the case of a 14-month-old girl who sustained a unilateral nondisplaced coronal suture fracture from a fall. She developed delayed intracranial hemorrhage from an underlying dural tear and cortical vein injury. Although an isolated skull fracture in a pediatric trauma patient typically portends a benign clinical course and may not require that the patient be hospitalized, a nondisplaced fracture across the coronal suture can lead to dural tear and intracranial injuries. High vigilance is warranted when evaluating CT images around the suture lines and treating pediatric patients with fractures across the coronal suture.
✓ The author reviews 400 cases of brain abscess treated in China over 20 years. The commonest cause was chronic ear infection, with abscesses in the temporal lobe and cerebellum. Signs of increased intracranial pressure were present in most cases, localizing neurological signs in two-thirds, and clinical signs of infection in only 57%. The difficulties of early diagnosis may be considerable. Definitive diagnosis was dictated by the techniques available: when clinical features and ultrasound indicated a localized abscess, a burr hole and exploratory aspiration were used; otherwise, and in complicated cases, angiography or ventriculography were required. Antibiotics were given in full doses for an extended period. Aspiration was the initial treatment in 253 cases, with 22% mortality. Excision was the sole treatment in 128 patients, of whom 17.2% died. A further 76 patients underwent aspiration followed by excision; 25% of these patients died. There was no significant difference in mortality in these treatment groups. The most important predictor of outcome was the patient's condition when first seen. In 103 cases, signs of brain herniation were present; the mortality was 64% in these patients. In the 297 without herniation, mortality was only 8.4%. Early referral for specialist care, computerized tomography, correct choice and dosage of antibiotics, and the surgical methods in present use should make this a benign disease.
Shu-Yuan Yang and Jian-Zhong Cui
Object. The goal of this study was to investigate the relationship between basic fibroblast growth factor (bFGF) gene expression and neuropathological changes in the hippocampus after varying degrees of brain injury.
Methods. Mild and severe brain injury in rats was produced by using Marmarou's method. There were 25 animals in each brain injury group and 25 additional animals served as controls. Basic fibroblast growth factor gene expression was investigated by means of RNA hybridization, in situ hybridization, immunohistochemical analysis, and histological analysis using hematoxylin and eosin staining.
A 3.7-kb bFGF messenger (m)RNA was detected in the rat hippocampus in both control and injured rats. In the mild injury group its expression was increased at 12 hours after injury and peaked on the 3rd day. Neuronal degeneration in the hippocampal CA2 and CA3 sectors was maximum on that day. In the severe injury group, the expression of the bFGF gene was the same as that in the mild injury group at corresponding times, but the number of surviving neurons in the CA2 and CA3 sectors was much lower than in the mild injury group. In situ hybridization showed that the main cells that expressed bFGF mRNA were pyramidal and granulocytic neurons in all three experimental groups. The number of neurons expressing bFGF mRNA in the severe injury group was less than that in the mild injury group, but the intensity of expression was greater. Immunohistochemical staining showed that the number of neurons expressing the bFGF protein was less in the severe injury group than in the mild injury group.
Conclusions. It is concluded that after mild injury there is a close relationship between the expression of the bFGF gene and the degree of histological change in the hippocampus; this indicates that as one of the growth factors, bFGF may participate in the protection and repair processes of neurons following brain injury. In severe injury there is a reduced expression of bFGF. The reason for this appears to be that more of the cells that have the potential to express bFGF have died, reducing the ability to express the bFGF gene. Conversely, it is possible that there may be an intrinsic insufficiency of expression of the gene, compatible with the known vulnerability of the hippocampus to many pathological conditions. Consideration should be given to supplying exogenous bFGF to protect the brain, particularly the hippocampus, after injury.
Xiaoguang Tong and Yuanfan Yang
Hongchao Yang, Youxiang Li and Yuhua Jiang
Insufficient platelet inhibition has been associated with an increased incidence of thromboembolic complications in cardiology patients undergoing percutaneous coronary intervention. Data regarding the relationship between insufficient platelet inhibition and thromboembolic complications in patients undergoing neurovascular procedures remain controversial. The purpose of this study was to assess the relationship of insufficient platelet inhibition and thromboembolic complications in patients with intracranial aneurysm undergoing stent treatment.
The authors prospectively recruited patients with intracranial aneurysms undergoing stent treatment and maintained the data in a database. MRI with diffusion-weighted sequences was performed within 24 hours of stent insertion to identify acute ischemic lesions. The authors used thromboelastography to assess the degree of platelet inhibition in response to clopidogrel and aspirin. Univariate and multivariate logistic regression analysis was used to identify potential risk factors of thromboembolic complications.
One hundred sixty-eight patients with 193 aneurysms were enrolled in this study. Ninety-one of 168 (54.2%) patients with acute cerebral ischemic lesions were identified by diffusion-weighted MRI. In 9 (5.4%) patients with ischemic lesions, transient ischemic attack or stroke was found at discharge, and these complications were found in 11 (6.5%) patients during the follow-up period. The incidence of periprocedural thromboembolic complications increased with resistance to antiplatelet agents, hypertension, hyperlipidemia, complete occlusion, and aneurysm of the anterior circulation. The multivariate regression analysis demonstrated that the anterior circulation and adenosine diphosphate (ADP) inhibition percentage were independent risk factors of perioperative thromboembolic complications. The maximum amplitude and ADP inhibition percentage were independent risk factors for thromboembolic complications during the follow-up period.
The ADP inhibition percentage is related to thromboembolic complications after stent placement for intracranial aneurysms. The increase of the ADP inhibition may decrease the risk of thromboembolic complications.
Yuxiang Cai, Yanjin Wang and Zhiquan Yang
Dysembryoplastic neuroepithelial tumors (DNETs) are benign intracranial tumors of neuroglial origin, mostly located in the supratentorial regions and particularly in the temporal lobe. Few cases of DNETs in the hypothalamus have been described. The authors present the case of a DNET in the hypothalamus. The 5-year-old girl with complaints of limb and gelastic seizures was admitted to the neurosurgical department of Xiangya Hospital. Neurological examination findings were unremarkable. MRI showed isointensity without significant enhancement on T1- and T2-weighted images. The lesion exhibited clearly defined borders on the sagittal, coronal, and axial images. The preliminary diagnosis was hypothalamic hamartoma (HH); however, the lesion was surgically removed, and histopathological examination confirmed the diagnosis of a DNET. Hypothalamic DNETs are extremely rare. Based on their clinical manifestation and imaging, DNETs are easily misdiagnosed as HHs. Diagnoses apart from HHs must be entertained when a hypothalamic lesion is being investigated.
Jack E. Sinclair and Yong H. Yang
Nan-Xiang Xiong and Hong-Yang Zhao
Shaohui He, Chen Ye, Nanzhe Zhong, Minglei Yang, Xinghai Yang and Jianru Xiao
The surgical treatment of an upper cervical spinal tumor (UCST) at C1–2/C1–3 is challenging due to anterior exposure and reconstruction. Limited information has been published concerning the effective approach and reconstruction for an anterior procedure after C1–2/C1–3 UCST resection. The authors attempted to introduce a novel, customized, anterior craniocervical reconstruction between the occipital condyles and inferior vertebrae through a modified high-cervical retropharyngeal approach (mHCRA) in addressing C1–2/C1–3 spinal tumors.
Seven consecutive patients underwent 2-stage UCST resection with circumferential reconstruction. Posterior decompression and occiput-cervical instrumentation was conducted at the stage 1 operation, and anterior craniocervical reconstruction using a 3D-printed implant was performed between the occipital condyles and inferior vertebrae via an mHCRA. The clinical characteristics, perioperative complications, and radiological outcomes were reviewed, and the rationale for anterior craniocervical reconstruction was also clarified.
The mean age of the 7 patients in the study was 47.6 ± 19.0 years (range 12–72 years) when referred to the authors’ center. Six patients (85.7%) had recurrent tumor status, and the interval from primary to recurrence status was 53.0 ± 33.7 months (range 24–105 months). Four patients (57.1%) were diagnosed with a spinal tumor involving C1–3, and 3 patients (42.9%) with a C1–2 tumor. For the anterior procedure, the mean surgical duration and average blood loss were 4.1 ± 0.9 hours (range 3.0–6.0 hours) and 558.3 ± 400.5 ml (range 100–1300 ml), respectively. No severe perioperative complications occurred, except 1 patient with transient dysphagia. The mean pre- and postoperative visual analog scale scores were 8.0 ± 0.8 (range 7–9) and 2.4 ± 0.5 (range 2.0–3.0; p < 0.001), respectively, and the mean improvement rate of cervical spinal cord function was 54.7% ± 13.8% (range 42.9%–83.3%) based on the modified Japanese Orthopaedic Association scale score (p < 0.001). Circumferential instrumentation was in good position and no evidence of disease was found at the mean follow-up of 14.8 months (range 7.3–24.2 months).
The mHCRA provides optimal access to the surgical field at the C0–3 level. Customized anterior craniocervical fixation between the occipital condyles and inferior vertebrae can be feasible and effective in managing anterior reconstruction after UCST resection.