External Decompression Research Articles

Long-term follow-up of cryopreservation with glycerol of autologous bone flaps for cranioplasty after decompressive craniectomy.

Autologous bone flaps adequately preserved can be used successfully for repair of cranial bone defects with biological and economic advantages. However, the effect or advantages of cryopreservation of autologous bone flaps using cryoprotectant solutions have not been investigated. The aim of this study was to investigate the utility of autologous bone flaps frozen with glycerol in cranioplasty after decompressive craniectomy. We evaluated postoperative complications and clinical and aesthetic results in 40 consecutive patients who underwent delayed cranioplasty using autologous bone flaps frozen with glycerol following decompressive craniectomy between 2001 and 2010. Bone flaps removed at the time of external decompression were dipped in 20 % glycerol solution with a sterilized plastic vessel and stored at -84 °C in an ultra-low temperature freezer. The bone flaps were thawed in the vessel at room temperature for 12 h. The bone flaps were taken out of melting glycerol, replaced in their original positions, and fixed with silk sutures or titanium plates. Follow-up periods ranged from 35 to 3745 days (median, 558 days). Mild resorption of the bone flap occurred in one case. However, there were no cases with local infection and no cases requiring reoperation for complications during the follow-up period. Cryopreservation with glycerol is a simple and safe method for preservation of autologous bone grafts. The clinical and aesthetic results of delayed cranioplasty using autologous bone flaps frozen with glycerol solution were satisfactory.

Combination of internal and external brain decompression due to repeated rupture and thrombosis of aneurysm with intracerebral haematoma: case report

Представлены результаты лечения больного по поводу разрыва и последующего тромбоза аневризмы средней мозговой артерии (СМА) слева, что осложнилось образованием внутримозговой гематомы и обширным инфарктом мозга в соответствующем бассейне. Острая внутричерепная патология сопровождалась коматозным состоянием. Больному проведено неотложное хирургическое вмешательство, которое включало обширную краниотомию и наружное вентрикулярное дренирование. После операции возникли септическое состояние и абсцесс легкого. Проведено хирургическое удаление абсцесса легкого в сочетании с антибактериальной терапией, введением пентоглобина и тималина. С начала заболевания пациенту назначена сочетанная антиоксидантная терапия. Пациент выписан для амбулаторного лечения. Через 2 года после операции его состояние относительно удовлетворительное.

Internal Decompression for Lumbar Spinal Stenosis—Indications, Technic, Results

Introduction The laminectomy, that is, the complete removal of the posterior wall of spinal canal, thus termed as external decompression, has been employed as traditional surgical method for lumbar spinal stenosis. The concept of unilateral laminotomy with bilateral decompression of the spinal canal based on thinning of the internal osseous surface of posterior canal wall instead of its removal was termed internal decompression. The success rate of decompression for lumbar spinal stenosis ranges from 57 to 95%.

Clinical Study on Cerebellar Contusion:A Report on 9 Cases and Literature Review

We report 9 cases of cerebellar contusion from April 2011 to September 2014 at our department. Frequency, clinicoradiological findings, mechanism of injury, treatments, and outcomes were retrospectively analyzed. Of 239 head injury cases admitted to our department during the same period, 9(3.8%)were diagnosed as cerebellar contusion. Among these 9 cases, 7 were men, and 2 were women. The patient age ranged from 12 to 83 years with a mean age of 64.7 years. The mechanism of injury was traffic accident in one patient, and fall in 8. All cases were associated with direct head trauma to the occiput, and radiographic studies showed occipital bone fracture in 8 cases. Six cases were managed conservatively. Three cases underwent suboccipital craniectomies and clot evacuations. Glasgow Outcome Scale(GOS)score at discharge were Good Recovery(GR)in 2, Moderate Disability(MD)in 2, Severe Disability(SD)in 3, Vegetative State(VS)in 1, and Dead(D)in 1. GOS scores in surgically treated cases were GR in 1, SD in 1, and VS in 1. Supratentorial severe traumatic lesions were concomitant with poor prognosis. Coup injury was a significant cause of cerebellar contusion. External decompression and clot evacuation were useful in patients who suffered severe cerebellar contusion;however, concomitant supratentorial lesions influenced the prognosis.

Cranioplasty and Duraplasty with Transcranial Color-Coded Duplex Sonography after Aneurysmal Subarachnoid Hemorrhage

Transcranial color-coded duplex sonography (TCCS) is a noninvasive technique for monitoring of cerebral vasospasm after neurosurgery for aneurismal subarachnoid hemorrhage. In this surgery, surgical materials are used. The goal of the study was to identify materials that can be used with ultrasound and to propose methods for cranioplasty and duraplasty using materials that permit TCCS. The chosen neurosurgical materials were titanium mesh plate (TMP), Gore-tex, SEAMDURA, gelatinous sponge, and oxidized cellulose. B-mode imaging was recorded with the materials placed between urethane resin 10 mm in diameter and the urethane phantom model. TCCS was performed to detect middle cerebral artery flow through TMP and Gore-tex. TMP and SEAMDURA permitted penetration of ultrasound in B-mode and Doppler imaging, but the other materials did not do so. A postcraniotomy window (PCW) on a line extending from the horizontal portion of M1 using only TMP permitted flow imaging with TCCS. In external decompression, TCCS was effective only without use of Gore-tex around the postcraniotomy window. This method allows the middle cerebral artery flow to be detected easily.

Bilobar stenting for tumors of the intrahepatic bile ducts

The article presents the experience of treating severe group of patients with proximal tumors of the biliary tract with lesions of the hepatic ducts. Of 1170 patients who underwent minimally invasive surgery for neoplastic lesions of the bile ducts, in 212 cases, stenting is performed when the tumor Klatskin, metastatic liver lesions and lymph nodes of the hepatoduodenal ligament. Used two-stage method of restoring patency of the bile ducts, in which the endoprosthesis was performed in most cases after a preliminary external decompression of biliary hypertension. In 207 cases was installed 2 stent in hepatic duct, in 5 cases – 3 stent. The authors have developed an algorithm for the management of patients in the postoperative period to prepare the patient for a possible radical surgical intervention, resulting in 6 cases it was possible to perform liver resection. In the postoperative period after radical surgery 1 patient died, after stenting operations in proximal tumor of the bile ducts mortality was 11.8%. The authors showed the effectiveness of minimally invasive technologies for restoring the patency of the tumor affected the hepatic ducts, which increases the median survival of patients with proximal tumors of the bile ducts, and also prepare a small group of patients for radical surgery.

Intrasylvian hematoma caused by ruptured middle cerebral artery aneurysms predicts recovery from poor-grade subarachnoid hemorrhage.

Intrasylvian hematoma (ISH) is a subtype of intracranial hematoma caused by aneurysmal rupture and often presents with a poor initial neurological grade; it is not well studied. The aim of this study was to elucidate outcomes of aneurysmal subarachnoid hemorrhage (SAH) with ISH. Data for 97 patients with poor-grade SAH (World Federation of Neurosurgical Societies Grade IV or V) were retrospectively analyzed from a single-center, prospective, observational cohort database. Ultra-early surgical clipping, removal of hematoma, external decompression for brain swelling, and prevention of vasospasm by cisternal irrigation with milrinone were combined as an aggressive treatment. Characteristics and clinical courses of SAH with ISH were identified. The authors also evaluated any correlations between poor admission-grade SAH and ISH with good functional outcome. Patients with poor admission-grade SAH and with ISH were more likely to have initial cerebral edema (p < 0.001, Mann-Whitney U-test), which significantly resolved overtime (p < 0.001, Mann-Whitney U-test). These patients had a better chance of functional survival (modified Rankin Scale scores of 1-3; OR 5.75; 95% CI 1.36-24.3; p = 0.017) at 6 months after hospital discharge, after adjustment for potential confounders such as younger age and better initial neurological grade by multivariable analysis. ISH predicted good functional recovery from poor-grade aneurysmal SAH.

Usefulness of repetitive intraoperative indocyanine green-based videoangiography to confirm complete obliteration of micro-arteriovenous malformations.

Background:It is difficult to intraoperatively confirm the total disappearance of arteriovenous (AV) shunts during surgery for microarteriovenous malformations (micro-AVMs), especially when the nidus is extremely small or diffuse on preoperative angiography. Although intraoperative angiography is effective for evaluating residual shunts, procedure-related risks raise important concerns. The purpose of this study was to assess the usefulness of intraoperative indocyanine green-based videoangiography (ICG–VA) to determine complete disappearance of micro-AVMs during surgery.Methods:We retrospectively analyzed eight patients with ruptured micro-AVMs who were treated using craniotomy with ICG–VA at our institution.Results:Two patients underwent emergency partial evacuation of hematoma and external decompression before the diagnostic angiography. While three patients had a nidus smaller than 1 cm, five patients had only early draining veins without an appreciable nidus. The draining veins were superficial in six cases and deep in two cases. The average interval from onset to surgery was 33 days (range, 2–57). ICG–VA was repetitively conducted until disappearance of the AV shunt was confirmed. No residual AV shunt was observed on postoperative radiological examinations. In all cases, the diagnosis of AVM was confirmed from the results of postoperative pathological examination.Conclusions:ICG–VA could detect early draining veins more clearly in situ than diagnostic angiography. Although it is not as effective for visualizing lesions with deep draining veins, repetitive ICG–VA was safe and effective for confirming the disappearance of AV shunts with superficial drainage.

Craniotomy or Craniectomy in Posterior Fossa Tumor Removal

Introduction: Normalization of craniocerebral proportion and prevention of hypertension syndrome development is one of the important specific aspects of neurosurgery. One of the most effective mechanisms for prevention of hypertension-dislocation syndrome is external decompression. This is mainly due to undying relevance of decompressive craniotomy (craniotomy), declared by Cushing at the beginning of the last century. Particularly, it’s became popular with operations in the posterior cranial fossa (PCF). Aim: A comparative characteristic of craniotomies in posterior cranial fossa tumor removal. Materials and Methods: The results of 126 suboccipital craniotomies in children under 17 year-old were studied. Subdural pressure over the cerebellum surface and pressure-volume proportion, as well as patients’ conditions in the early postoperative period were monitored. Results: The results of uncomplicated operations were compared. In subtotal or total removal of PCF tumors were not observed cerebellar edema, compression and deformation of the brainstem, hence no need for external decompression. Over the past 10 years only 4% of cases it was necessary to carry out decompressive suboccipital craniotomy. Conclusion: Therefore, decompressive craniotomy should not be considered as an alternative method of approach for PCF tumor removal. So, suboccipital osteoplastic craniotomy is a method of choice. Under certain conditions craniotomy may be minimal (only occipital bone squama resection is sufficient) with involvement of foramen magnum edges and posterior arches of CI-II vertebras.

Thyroid storm in a child after severe head injury and neurointensive care.

We report a rare pediatric case of thyroid storm (TS) after severe head injury and neurointensive care. A 14-year-old, previously healthy girl was transported to our hospital by ambulance after losing consciousness in a traffic accident. On arrival, her Glasgow Coma Scale score was 4 (eye, 1; verbal, 1; motor, 2). Her pupils were mydriatic and did not react to light. A computed tomography scan showed a 6-mm left subdural hematoma with a 5-mm midline shift. An emergency craniotomy for removal of the hematoma and external decompression were carried out after temporary trepanation, and therapeutic hypothermia (THT) was maintained for 10 days because of severe brain edema. After rewarming, she remained comatose and her temperature was controlled with acetaminophen. Beginning on day 21, her body temperature increased to more than 38°C and she had tachycardia (>130 b.p.m.), diarrhea, and an abnormally diaphoretic appearance. Thyroid function tests were carried out on day 24. The thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) levels were <0.005 μIU/mL, 5.0 ng/dL, and 13.5 pg/mL, respectively, and the TSH receptor antibody level was 11.7 IU/mL. Thyroid storm was diagnosed on the basis of Japan Thyroid Association criteria.1 Treatment with methimazole, corticosteroids, propranolol, and potassium iodide was started, and her fever and tachycardia gradually improved. On day 29, a cranioplasty and a tracheotomy were carried out without TS. Her impaired consciousness gradually improved, and she was discharged to another hospital for rehabilitation on day 105. At discharge, her Glasgow Coma Scale score was 11 (eye, 4; verbal, T; motor, 6) and her Glasgow Outcome Scale score was 3. Her final TSH, FT4, and FT3 levels were <0.005 μIU/mL, 1.5 ng/dL, and 3.7 pg/mL, respectively, with 10 mg/day methimazole. Thyroid storm has been reported to be induced by invasive events such as surgery, infection, or trauma.1 However, trauma and surgery are less common causes of TS than irregular use of antithyroid drugs and infection.1-3 Thyroid storm is the most critical complication of hyperthyroidism and a cause of mortality if the diagnosis is delayed.4 Although diagnosis is usually based on suspicions related to symptoms, the symptoms are not specific. This is especially true in patients with impaired consciousness caused by a primary illness, making diagnosis and satisfaction of criteria more difficult. In addition, a definitive diagnosis is impossible without carrying out thyroid function tests. In the present case, after the diagnosis of TS, we retrospectively checked the patient's thyroid hormone level before rewarming using the blood sample from day 10; the TSH, FT4, and FT3 levels were <0.005 μIU/mL, 2.5 ng/dL, and 4.4 pg/mL, respectively. Although she had no symptoms before the traffic accident, our findings suggest that she had underlying hyperthyroidism during THT. The present case suggests that THT with sedation suppresses severe stress-induced reactions, including TS, and rewarming then reveals the symptoms symptoms (Fig. 1). Clinical course of a pediatric case of thyroid storm (TS) after severe head injury and neurointensive care. Dashed lines indicate retrospective results of thyroid hormone level. BT, body temperature; ETMS, external temperature management system; FC, fever control; FT3, free triiodothyronine (pg/mL); FT4, free thyroxine (ng/dL); GCS, Glasgow Coma Scale; HR, heart rate; KI, potassium iodide; NT, normothermia; OP, operation; PP, propranolol; St, steroids; TSH, thyroid-stimulating hormone (μIU/mL); THT, therapeutic hypothermia. In conclusion, even if there is no history of hyperthyroidism, careful observation and early thyroid function tests in a patient with suggestive symptoms, especially after rewarming, may be useful for diagnosis of TS during neurointensive care, including THT, after severe head injury. None.

Generalized Auditory Agnosia following a Subarachnoid Hemorrhage; A case report

A 65-year-old male developed a subarachnoid hemorrhage(SAH) caused by a ruptured right internal carotid artery-posterior communicating artery aneurysm. Clipping of the aneurysm, removal of the hematoma, and external decompression were performed. Thereafter, he developed a bacterial meningitis after a spinal lumbar drainage that was done for the treatment of hydrocephalus. He was admitted to our hospital for rehabilitation 4 months after the onset of the SAH. He was still lethargic and delirious at the time of admission. He could not recognize spoken words, environmental sounds or music one month later, but was able to speak and understand the written words. He was diagnosed to have generalized auditory agnosia, based on almost normal pure tone audiometry, otoacoustic emission test, and ABR. Brain CT disclosed a right temporal and frontal lesions, but not in the left side. The eZIS and vbSEE analysis of the SPECT images disclosed a lesion in the left Heschl's transverse gyrus that could not be detected on CT. We emphasized that the detailed analysis of the SPECT images is useful to demonstrate the lesions that can not be detected by CT. ACTA MEDICA NAGASAKIENSIA 57: 99－103, 2012

Temporal changes in CT perfusion values before and after cranioplasty in patients without symptoms related to external decompression: a pilot study

Little is known about hemodynamic disturbances affecting cerebral hemispheres in traumatic brain injury (TBI) after cranioplasty. We prospectively investigated six stable TBI patients who underwent cranioplasty more than 90 days after effective decompressive craniectomy. Computerized tomography perfusion (CTP) studies and evaluation of clinical outcome were performed for each patient before cranioplasty and at 7 days and 3 months after surgery. Cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) were measured in multiple cortical circular regions positioned in cranioplasty-treated and contralateral hemispheres. Neither complications associated with cranioplasty nor changes in outcome were observed. On the treated side, CBF and CBV values were higher before and 7 days after cranioplasty than at 3 months after surgery, whereas MTT values were lower at 7 days than at 3 months after surgical treatment. Our results indicate that cortical perfusion progressively declines in the cranioplasty treated hemisphere but remains stable in the contralateral hemisphere after surgery and suggest that CTP can represent a promising tool for a longitudinal analysis of hemodynamic abnormalities occurring in TBI patients after cranioplasty. In addition, these data imply a possible role of cranioplasty in restoring flow to meet the prevailing metabolic demand.

The efficacy of external decompression for severe traumatic brain injury

Objective To explore the efficacy of large decompressive craniectomy for patients with severe traumatic brain injury.Methods The clinical data on 72 patients with severe traumatic brain injury who had been admitted to our hospital during the period of January 2009 to August 2012 were retrospectively reviewed.All the patients were treated by large decompressive craniectomy.Results 64 of the 72 patients survived; while 8 died intraoperatively and postoperatively because of delayed treatment.The survivors were graded according to the Glasgow Outcome Scale (GOS) in a follow-up of 1 to 2 years.38 survivors has better recovery,14 were moderately disable,9 were severely disable,and 3 were in vegetative state.Of 8 patients who were dead,4 died of severe brainstem injury,2 died of severe complications,and the rest 2 died from abandonment of treatment.Conclusions Large decompressive craniectomy is efficacious in the treatment of severe traumatic brain injury. Key words: Severe traumatic brain injury; External decompression; Efficacy

Cerebral and Subdural Abscess With Spatio-temporal Multiplicity 12 Years After Initial Craniotomy for Acute Subdural Hematoma

A 34-year-old man presented with a case of subdural empyema and cerebral abscess that developed 12 years after initial neurosurgical intervention for a traffic accident in 1998. Under a diagnosis of acute subdural hematoma and cerebral contusion, several neurosurgical procedures were performed at another hospital, including hematoma removal by craniotomy, external decompression, duraplasty, and cranioplasty. The patient experienced an epileptic seizure, and was referred to our hospital in March 2010. Magnetic resonance imaging revealed a cerebral abscess extending to the subdural space just under the previous surgical field. Surgical intervention was refused and antimicrobial treatment was initiated, but proved ineffective. Surgical removal of artificial dura and cranium with subdural empyema, and resection of a cerebral abscess were performed on May 12, 2010. No organism was recovered from the surgical samples. Meropenem and vancomycin were selected as perioperative antimicrobial agents. No recurrence of infection has been observed. Postneurosurgical subdural empyema and cerebral abscess are recently emerging problems. Infections of neurosurgical sites containing implanted materials occur in 6% of cases, usually within several months of the surgery. Subdural empyema and cerebral abscess developing 12 years after neurosurgical interventions are extremely rare. The long-term clinical course suggests less pathogenic organisms as a cause of infection, and further investigations to develop appropriate antimicrobial selection and adequate duration of antimicrobial administration for these cases are needed.

Two Patients with Moyamoya Disease Underwent Emergency Cesarean Delivery Resulted in Opposite Outcomes

Moyamoya disease is a rare cerebrovascular disorder, characterized by bilateral stenosis or occlusion of arteries at the base of the brain and formation of an abnormal network of collateral vessels, called moyamoya vessels, associated with cerebral hemorrhage and infarction. No appropriate method of delivery, anesthesia, and perioperative management of pregnant patients with moyamoya disease has yet been established. We report 2 cases of pregnant patients with moyamoya disease who underwent emergency cesarean delivery under general anesthesia. The postoperative courses were different, which might help us establish a protocol for the standard management of this disease. Case 1: A 33-year-old primipara was diagnosed as having moyamoya disease when she was 4-year-old. She underwent emergency cesarean delivery under general anesthesia at 37 weeks’ gestation due to early rupture of the membranes. The perioperative period was uneventful. The patient was discharged without aggravation of neurological symptoms. Case 2: A 35-year-old multipara with no medical history experienced sudden nausea and headache disturbance at 30 weeks’ gestation. Brain CT showed intracranial hemorrhage, and the patient was diagnosed moyamoya disease by cerebral angiography. The patient recovered after intraventricular drainage but lost consciousness at 32 weeks’ gestation due to repeated hemorrhage. Cesarean delivery, aneurysm excision, direct hematoma evacuation, and external decompression were performed shortly thereafter under general anesthesia. The intracranial pressure continued to increase, and the patient died on the ninth postoperative day. In pregnant patients with moyamoya disease, careful management during the perinatal period is needed to decide the timing of emergency cesarean delivery, which affects prognosis.

脳血管攣縮 くも膜下出血後脳血管攣縮期の脳血流評価におけるｖａｓｏｐａｒａｌｙｓｉｓの頻度と病態に関しての検討

We employ the 123I-IMP SPECT dual table ARG method and stereotactic extraction estimation (SEE) analysis 7 or 8 days after subarachnoid hemorrhage (SAH) onset to predict cerebral vasospasm. We report new findings of cerebral vasoparalysis during a period of cerebral vasospasm after SAH. From January 1, 2005 to April 30, 2008, we encountered 330 cases of aneurysmal SAH, and treated 285 cases. Of these, 65 were excluded as unsuitable for this study, for reasons such as lack of SPECT data, external decompression, admission over 7 days from SAH onset. We studied 220 cases treated by microsurgical clipping (n＝178) or endovascular coil embolization (n＝42). Vasoparalysis was defined as a rise in resting CBF and a loss of vascular reserve on SEE analysis of CBF-SPECT. Vasoparalysis occurred in 15 cases (6.8%). Of these, 9 cases (60.0%) had cerebral hematoma, temporary clips had been used in the operation for 8 cases (53.3%), 9 cases (60.0%) experienced postoperative cerebral infarction, and 3 cases (20.0%) had postoperative convulsions. Vasoparalysis occurs in relation to perioperative cerebral damage. In terms of the loss of vascular reserve following SAH, vasoparalysis resembles hemodynamic cerebral ischemia, although the conditions are quite different. Differentiating between these 2 conditions is important, as different forms of management are required. Dual table ARG and SEE analysis are very useful for the evaluating these 2 conditions.

Utility of the Orbitocranial Approach for Clipping of Anterior Communicating Artery Aneurysms: Significance of Dissection of the Interhemispheric Fissure and the Sylvian Fissure

To investigate the importance of sufficient dissection of the interhemispheric and sylvian fissures, an orbitocranial approach was used for clipping of ruptured anterior communicating artery aneurysms. From January 1998 through March 2009, 41 patients underwent surgery for subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm. Their mean age was 58.4 years, with a range of 37 to 84 years. The preoperative World Federation of Neurosurgical Societies grade was I to III in 32 patients and IV to V in 9 patients. The direction of the aneurysm was upward in 23 patients, forward in 14 patients, and backward in 4 patients. Seven patients had a large aneurysm. All patients underwent surgery during the acute stage following the subarachnoid hemorrhage (day 0-2). A right orbitocranial approach was used for most patients, but a left orbitocranial approach was used for 9 patients because of the presence of a complicated aneurysm and the positional relationship of the left-right A2 segment. In 12 patients, external decompression was performed. The outcome, using the Glasgow Outcome Scale, was good recovery in 24 patients, moderately disabled in 8 patients, and severely disabled in 4 patients, and 5 patients died. Temporary eye movement disorders developed after surgery in 5 patients but resolved in all patients within 2 months. No patients had olfactory disturbance. Using the orbitocranial approach and sufficient dissection of the interhemispheric and sylvian fissures, we could secure a broad field of vision and surgical field, which contributed to a safe operation. The only postoperative complication caused by the surgical approach was temporary eye movement disorder. Thus, for some patients with aneurysms of the anterior communicating artery, the orbitocranial approach contributes to improved outcomes.

Should Decompressive Surgery Be Performed in Malignant Cerebral Venous Thrombosis?

Background and Purpose— In malignant cerebral venous thrombosis (CVT) patients, emergency decompressive surgery has been suggested as a life-saving procedure. We report 12 patients with malignant CVT, among whom 8 underwent operation. Methods— Retrospective study of 12 patients from 3 stroke units who had a malignant CVT as defined: (1) supratentorial cortical lesions attributable to superficial venous system thrombosis with or without sinus involvement; (2) with clinical (decreased consciousness and dilated pupils) or radiological signs of transtentorial herniation; (3) either at onset or after worsening despite heparin therapy. Surgery or abstention was decided individually by neurosurgeons on call. Results— There were 9 women and 3 men with a mean age of 45±15 years. The delay between heparin therapy and signs of malignancy ranged from 2 to 30 hours. At malignant worsening all but 1 patient had hemorrhagic lesions; the median deviation of septum pellucidum was 12 mm (interquartile range, 6.7–13); 5 patients (including 3 who underwent operation) had a unilateral dilated pupil; and 4 (2 who underwent operation) had bilateral dilated pupils. Eight patients underwent surgical decompression, external decompression in 4, both external and internal decompression in 3, and internal decompression in 1. The 4 patients who did not undergo operation died within 1 to 5 days after diagnosis. One patient who underwent operation died of a pulmonary embolism. The 7 others survived, with, at last follow-up (median, 23.1 months; interquartile range, 19.7–45.6), an excellent recovery of mRS 0 or 1 in 6 and mRS 3 in 1. Conclusion— Decompressive surgery may save lives and may even allow a good functional outcome in malignant CVT, even in patients with bilateral dilated pupils.

Poor-Grade Ruptured Middle Cerebral Artery Aneurysm With Intracerebral Hematoma: Bleeding Characteristics and Management

Poor-grade ruptured middle cerebral artery aneurysm is frequently associated with intraparenchymal hemorrhage, which is associated with high morbidity rates. We analyzed the clinical presentations and surgical strategies of 23 cases of ruptured middle cerebral artery aneurysm. Hematomas were divided into three types: temporal hematoma (7 patients), sylvian hematoma (10 patients), and frontal hematoma (6 patients). In 13 of 23 patients, preoperative brainstem symptoms suggested impeding uncal herniation. Surgical procedures included external decompression in 11 patients, simple lateral temporal lobectomy in 5, and selective uncectomy in 9. Three patients died. Favorable outcome defined as upper half of severely disabled or better in the extended Glasgow Outcome Scale was achieved in 13 patients. Patients with frontal hematomas presented with both uncal herniation and brainstem signs preoperatively, but this subgroup showed unexpectedly good recovery. Patients with sylvian hematomas had relatively poor outcomes. The present series suggests that aggressive decompression and evacuation of hematoma in the acute stage may prevent significant postoperative brain swelling, and will not compromise the treatment of vasospasm.

Retrospective Review of Microsurgical Repair of 222 Lingual Nerve Injuries

Injury to the lingual nerve (LN) is a known complication associated with several oral and maxillofacial surgical procedures. We have reviewed the demographics, timing, and outcome of microsurgical repair of the LN. A retrospective chart review was completed of all patients who had undergone microsurgical repair of the LN by one of us (R.A.M.) from March 1986 through December 2005. A physical examination, including standardized neurosensory testing, was completed of each patient preoperatively. All patients were followed up periodically after surgery for at least 1 year, with neurosensory testing repeated at each visit. Sensory recovery was determined from the patient's final neurosensory testing results and evaluated using the guidelines established by the Medical Research Council Scale. The following data were collected and analyzed: patient age, gender, nerve injury etiology, chief sensory complaint (numbness or pain, or both), interval from injury to surgical intervention, intraoperative findings, surgical procedure, and neurosensory status at the final evaluation. The patients were classified according to whether they achieved "useful sensory recovery" or better, according to the Medical Research Council Scale, or had unsatisfactory or no improvement in sensation. Logistic regression methods and associated odds ratios (OR) were used to quantify the association between the risk factors and improvement. Receiver operating characteristic curve analysis was used to find the age threshold and duration that maximally separated the patient outcomes. A total of 222 patients (51 males and 171 females; average age 31.1 years, range 15 to 61) underwent LN repair and returned for at least 1 year of follow-up. The most common cause of LN injury was mandibular third molar removal (n = 191, 86%), followed by sagittal split mandibular ramus osteotomy (n = 14, 6.3%). Most patients complained preoperatively of numbness (n = 122, 55%) or numbness with pain (n = 94, 42.3%). The average interval from injury to surgery was 8.5 months (range 1.5 to 96). The most commonly performed operation was excision of a proximal stump neuroma with neurorrhaphy (n = 154, 69%), followed by external decompression with internal neurolysis (n = 29, 13%). Nineteen patients (8.6%) underwent an autogenous nerve graft procedure (greater auricular or sural nerve) for reconstruction of a nerve gap. A collagen cuff was placed around the repair site in 8 patients (3.6%; external decompression with internal neurolysis in 2 and neurorrhaphy in 6). Recovery from neurosensory dysfunction (defined by the Medical Research Council Scale as ranging from "useful sensory function" to a "complete return of sensation") was observed in 201 patients (90.5%; 146 patients with complete recovery and 55 patients with recovery to "useful sensory function"), and 21 patients (9.5%) had no or inadequate improvement. Using the logistic regression model, a shorter interval between nerve injury and repair resulted in greater odds of improvement (OR 0.942, P = .0064); with each month that passed, the odds of improvement decreased by 5.8%. The receiver operating characteristic analysis revealed that patients who waited more than 9 months for repair were at a significantly greater risk of nonimprovement. Statistical significance was observed between patient age and outcome (OR 0.945, P = .0067) representing a 5.5% decrease in the chance of recovery for every year of age in patients 45 years old and older. The odds of a return of acceptable neurosensory function were better when the patient's presenting symptom was pain and not numbness (OR 0.04, P < .001). Microsurgical repair of LN injury has the best chance of successful restoration of acceptable neurosensory function if done within 9 months of the injury. The likelihood of recovery after nerve repair decreased progressively when the repair occurred more than 9 months after injury and with increasing patient age.