Trephine Hole Research Articles

Chronic ear disease as a possible reason for trephination

AbstractIt is rare for any reason to be deduced for the operation of trephination. A Peruvian skull is presented with three trephine holes on one side and evidence of the chronic ear infection known as cholesteatoma on the other. This infection would have produced a facial paralysis on the same side. It is suggested that there would have been an awareness of the connection between the motor area of the brain on one side and the movement of the opposite side of the body, and that a trephination might have been carried out in an attempt to relieve a supposed brain lesion, albeit on the wrong side.

Combined Use of Subdural and Intracerebral Electrodes in Preoperative Evaluation of Epilepsy

Abstract For intracranial recording of partial seizures considered to originate from one of the temporal or frontal lobes, the team in the Utrecht Academic Hospital has used subdural, multicontact, flexible electrodes since 1972. These are introduced through bilateral, frontocentral trephine holes and are manipulated under fluoroscopy to cover most of the cerebral convexity. It became evident that in many patients, additional placements to record from intracerebral structures were indispensable. Therefore, using the same trephine holes, an additional 2 to 4 depth electrodes were stereotactically implanted in the mesial temporal and/or frontal structures, as appropriate. An extensive intra- and extracerebral spatial representation of the epileptogenic zone was thus obtained. We report here the methods for manufacturing and applying these electrodes and our clinical experience with 28 patients. The results obtained so far stress the value of combining subdural and depth electroencephalographic monitoring in the presurgical selection of patients suffering from medically refractory complex partial seizures. By miniaturizing the electrodes, extensive areas of the brain can be investigated without craniotomy or multiple burr holes. (Neurosurgery 26:93-101, 1990)

Combined use of subdural and intracerebral electrodes in preoperative evaluation of epilepsy

For intracranial recording of partial seizures considered to originate from one of the temporal or frontal lobes, the team in the Utrecht Academic Hospital has used subdural, multicontact, flexible electrodes since 1972. These are introduced through bilateral, frontocentral trephine holes and are manipulated under fluoroscopy to cover most of the cerebral convexity. It became evident that in many patients, additional placements to record from intracerebral structures were indispensable. Therefore, using the same trephine holes, an additional 2 to 4 depth electrodes were stereotactically implanted in the mesial temporal and/or frontal structures, as appropriate. An extensive intra- and extracerebral spatial representation of the epileptogenic zone was thus obtained. We report here the methods for manufacturing and applying these electrodes and our clinical experience with 28 patients. The results obtained so far stress the value of combining subdural and depth electroencephalographic monitoring in the presurgical selection of patients suffering from medically refractory complex partial seizures. By miniaturizing the electrodes, extensive areas of the brain can be investigated without craniotomy or multiple burr holes.

Effect on biochemical markers of brain injury of therapy with deferoxamine or superoxide dismutase following cardiac arrest

Iron-mediated lipid peroxidation by oxygen radical mechanisms is thought to be a contributing factor to neurological injury during reperfusion following resuscitation from cardiac arrest. This study was designed to examine and compare the effects of an iron chelator (deferoxamine) and superoxide dismutase (SOD) on brain lipid peroxidation and tissue ions after eight hours of reperfusion following a 15-minute cardiac arrest. This sampling time was chosen because other work with this model has shown severe ionic and ultrastructural derangement at this point. Twenty-three dogs were anesthetized with ketamine and halothane and divided into four groups. Six dogs were nonischemic controls (group I). In the remaining dogs, a 15-minute cardiac arrest was induced with KCl. Resuscitation was begun with internal cardiac massage and artificial ventilation. After five minutes of artificial perfusion, internal defibrillation was performed to restart the heart. All dogs were resuscitated and supported by a standard intensive care (SIC) protocol for eight hours. Six resuscitated dogs served as SIC controls (group II). Six were treated with deferoxamine, 200 mg/kg loading dose and 100 mg/kg/h maintenance drip (group III), and five were treated with SOD, 1,000,000 units bolus and 500,000 units/h drip (group IV). All drugs were administered intravenously immediately postresuscitation. At eight hours postresuscitation, a 3-g portion of parietal cerebral cortex was obtained through a trephine hole. The sample was assayed for tissue malondialdehyde (MDA) by the thiobarbituric acid test, the double bond content of the tissue lipids (lipid unsaturation index, LUSI), and total tissue content of K and Na. Deferoxamine treatment inhibited peroxidation of brain lipids by both the MDA and LUSI assays, and protected tissue K Na ratio. SOD treatment inhibited only MDA. Iron chelation therapy appears to be promising for the membrane component of reperfusion injury.

Evaluation in cats of a new material for cranioplasty: a composite of plaster of Paris and hydroxylapatite.

The materials ordinarily used to reconstruct bone defects in the calvaria and facial bones either are difficult to shape, are partially resorbed by the body, or are likely to become infected if used near a contaminated area such as the frontal sinus. Calcium sulfate hemihydrate (plaster of Paris) has been known for years to have excellent reparative qualities in bone defects, but ordinarily it is quickly resorbed. Consequently, a new material, a composite of a dense form of plaster of Paris and hydroxylapatite, was devised to provide nonabsorbable hydroxylapatite particles for bone to form around and within during the phase of plaster absorption. Two types of this material were evaluated in cranial defects in cats. Each of the plaster of Paris/hydroxylapatite mixtures was placed into a surgically unroofed frontal sinus and into a contralateral parietal trephine hole in a group of 32 cats. Two cats in each group succumbed to anesthesia, leaving two sets of 30 cats. During the entire follow-up period there was only one other death, with no evidence of wound infection, wound dehiscence, implant rejection, or cerebral dysfunction among the survivors. The cats in each group were sacrificed at 1, 2, 3, 5, 7, 8, 9, 10, or 12 months after operation. Following sacrifice, both the frontal and parietal defects were exposed and examined visually, histologically, and with histomorphometric analysis for new bone formation. New bone formation was present as early as 1 month after operation and continued to increase during the 12 months of the study. Based upon these osteogenic qualities, the ease of shaping the composite, and the lack of infection in the frontal sinus region, it is concluded that this substance could be a valuable new material for human cranioplasty.

Loss of the neural integrator of the oculomotor system from brain stem lesions in monkey.

Eye movement were recorded from four juvenile rhesus monkeys (Macaca mulatta) before and after the injection of neurotoxins (kainate or ibotenate) in the region of the medial vestibular and prepositus hypoglossi nuclei, an area hypothesized to be the locus of the neural integrator for horizontal eye movement commands. Eye movements were measured in the head-restrained animal by the magnetic field/eye-coil method. The monkeys were trained to follow visual targets. A chamber implanted over a trephine hole in the skull permitted recordings to be made in the brain stem with metal microelectrodes. The abducens nuclei were located and used as a reference point for subsequent neurotoxin injections through cannulas. The effects of these lesions on fixation, vestibuloocular and optokinetic responses, and smooth pursuit were compared with predicted oculomotor anomalies caused by a loss of the neural integrator. Kainate and ibotenate did not create permanent lesions in this region of the brain stem. All the eye movements returned toward normal over the course of a few days to 2 wk. Histological examination revealed that the cannula tips were mainly located between the vestibular and prepositus hypoglossi nuclei, in their rostral 2 mm, bordered rostrally by the abducens nuclei. Dense gliosis clearly demarcated the cannula tracks, but for most injections there were no surrounding regions of neuronal loss. Thus the eye movement disorders were due to a reversible, not a permanent, lesion. The time constant for the neural integrator was determined from the velocity of the centripetal drift of the eyes just after an eccentric saccade in total darkness. For intact animals this time constant was greater than 20 s. Shortly after bilateral injections of neurotoxin, the time constant began to decrease and reached a minimum of 200 ms; every horizontal saccade was followed by a rapid centripetal drift with a time constant of approximately 200 ms. For vertical eye movements, in this acute phase, the time constant was approximately 2.5 s. The vestibuloocular reflex (VOR) was drastically changed by the lesions. A step of constant head velocity in total darkness evoked a step change in eye position rather than in velocity. In the absence of the neural integrator, the step velocity command from the canal afferents was not integrated to produce a ramp of eye position (normal slow phases); rather this signal was relayed directly to the motoneurons and caused a step in eye position. The per- and postrotatory decay of the head velocity signal was decreased to 5-6 s indicating that vestibular velocity storage was also impaired.(ABSTRACT TRUNCATED AT 400 WORDS)

Results of sclera-laminating goniotrephination in neovascular glaucoma

Sclera-laminating goniotrepanation is a modification of the Elliot-Fronimopoulos operation. In this procedure the scleral flap is removed, so that a shallow depression is formed in the sclera; this helps to prevent an ectatic bleb. No cicatrization of the trephine hole was observed in the authors' cases. The modification is only used by them in glaucoma cases with poor prognosis. Forty-six patients, 39 of whom were suffering from neovascular glaucoma associated with occlusion of the central retinal vein or diabetic retinopathy, underwent the operation and the results were followed up. As far as regulation of intraocular pressure and elimination of pain are concerned, the results were encouraging. Severe hemorrhage into the anterior chamber without spontaneous absorption only occurred in 2 cases.

Ultrasound sector scanning for the localization and biopsy of intracerebral lesions.

A technique is described for the intraoperative use of ultrasound sector scanning in intracerebral neoplasms (mainly gliomas) for biopsy and for the localization of minor lesions. Altogether, 13 patients underwent sonographic examination: nine had gliomas, one had a meningioma, and three had metastases. Through a trephine hole or a bone flap over the tumor, the ultrasound transducer easily localized the lesion in all cases but one. The striking concordance between the sonogram and the corresponding computerized tomography scan made it easy to take several biopsies from areas where the tumor tissue was suspected to be representative. The results show a close correlation between the biopsy specimen and the specimen obtained at extirpation. In two cases, ultrasonic scanning served as an aid for the surgeon in localizing the tumor prior to removal.

The relationship between pressure regulation and anatomic localization as well as trephine sites in goniotrepanation. A prospective study

Long-term regulation of IOP after trephining procedures was studied in 65 eyes with regard to the anatomical localization of the trephine hole. The observation period ranged between six and 39 months. The anatomical localization had no statistically significant influence on long-term pressure regulation after surgery, nor on the immediate postoperative situation. It was clinically impossible to localize the trephine within the trabecular area including Schlemm's canal with a high degree of accuracy. The use of larger-diameter trephines did not increase the probability of striking Schlemm's canal. With larger-diameter trephines the immediate effect on IOP was more pronounced, but the long-term IOP response was poorer. The absence of a filtering bleb or the development of a large filtering bleb was significantly more often associated with poor regulation of IOP in the long term. Where the trephine was positioned closer to the sclera, the incidence of choroidal detachment was higher. The diameter of the trephine had no effect on the occurrence of postoperatively flat chambers or choroidal detachments. Nor did the anatomical localization influence the incidence of postoperatively flat chambers.

Histological findings following Elliot-Fronimopoulos trephination (author's transl)

In histological examinations with serial sections an open trephination hole and a persistent slitlike space between the scleral flap and the sclera were found up to 17 months after Elliot-Fronimopoulos goniotrephination with scleral flap. This condition could be the "parathalamus" described by Fronimopoulos et al.

Fronto-facial advancement for Crouzon's and Apert's syndromes.

This paper reviews the evolution of the surgical approach to the facial deformities in Crouzon's and Apert's syndromes. Since the first high maxillary osteotomy performed via an extracranial approach, various procedures have been used. These procedures were, successively, the intracranial route permitting simultaneous advancement of the mid-face and frontal bone in adult; then the use of trephine holes to protect the dura and brain during osteotomies obviating the need for a craniotomy. Likewise, more precise craniofacial fixation by interosseous wiring and bone grafting frequently obviate the need for intermaxillary fixation. More recently the fronto-facial advancement in one piece has been used in children between 4 and 10 years of age. The advantages and disadvantages of this procedure are considered.

Temporal lobe lesions in head injury.

In cases of closed head injury temporal lobe lesions e.g. contusion, laceration, pulping, or intracerebral haematoma frequently result in an expanding process. These are frequently associated with an overlying subdural haematoma. Eighty five cases of such lesions from a consecutive series of 1,000 cases of head injury have been analyzed. The lesions are caused by severe injury resulting in loss of consciousness and skull fracture. Most of them are contre-coup lesions. Clinically they manifest themselves like any other acute or subacute intracranial hematoma. The majority of the patients have contralateral hemiparesis and pupillary abnormalities. Carotid angiography is valuable for diagnosis. These lesions are likely to be missed when exploratory burr holes are made or, are erroneously diagnosed as acute subdural haematoma or brain oedema. Smaller lesions, not showing progressive deterioration, may respond to conservative treatment. However, surgical decompression is essential in most cases A frontotemporal osteoplastic craniotomy or a large Scoville trephine hole is essential to deal with these lesions adequately.

Self-contained tubular drill guard for anterior cervical fusion.

A self-contained tubular drill guard was adapted for use in performing anterior cervical discectomies and interbody fusions. The use of this instrument eliminates steps, provides absolute safety against drilling too deeply, allows for adjustment in individual cases, provides for easy inspection of the trephine hole, permits electing the cephalocaudal angle of the drill, and gives a measurement of the ultimate depth of the trephine hole. In 171 consecutive operations only one neurological complication occurred, and total morbidity related to cervical surgery was 6% (7% morbidity was associated with surgery at the donor site). The data suggest that the technical modification herein advocated reduces the surgical complication rate.

Epidural electrode for animals with thin skulls

A small spheroidal electrode of base metal was made and placed in the epidural space through a trephine hole in the gerbil's skull to obtain precision EEG recordings.

Unusual Anatomo-Pathological Finding in Long-Term Survival after Cardiac Arrest

Operation for a subdural haematoma in a 3½ month-old boy caused severe loss of blood, with cardiac arrest lasting for 30 min. By external heart massage a minimal residual circulation was secured. Survival was 11 months in a decerebrated state. Histological examination revealed widespread cortical necrosis due to severe hypotension and oligaemia, the cortex under the trephination hole remaining unaffected. Thus, that part of the brain which was not compressed could escape during the presumed concomitant brain swelling, remained intact, and its blood supply became relatively better. According to the authors this case supports the hypothesis that cerebral swelling may play an important role in the development of hypoxic-ischaemic states.

A method for recording single unit activity from unanesthetized chronic cats

Under general anesthesia the cat is held in a stereotaxic instrument and a screwcapped teflon cylinder is placed in a trephine hole over the area from which microelectrode recordings are to be made. Macroelectrode leads are connected to an Amphenol receptacle which is screw-fastened into a head-holding apparatus which is rigidly attached to the stereotaxoc instrument. The receptacle is dental-cemented to the skull of the cat so that when ear, eye and mouth bars are removed, the head of the animal is still rigidly held in the stereotaxic position. During unit recording, the cat is held in a restraining box and the Amphenol plug is again fastened to the head-holding device and stereotaxic frame. The teflon cylinder is uncapped and a microelectrode is stereotaxically lowered into the brain of the cat. Cats adapt to the body and head restraint and single cells have been recorded for several hours.

X-ray manifestations of the Holter valve in hydrocephalus.

The exact mechanism of production and absorption of cerebrospinal fluid remains in question. Also lacking is a clear understanding of the alternate pathways that can develop when the normal flow of cerebrospinal fluid is obstructed. When there is obstruction to the ventricles, overproduction or poor absorption of cerebrospinal fluid, the resulting high-pressure hydrocephalus destroys brain tissue. A number of operative shunting procedures have been developed to allow egress of the fluid from the ventricular system and thus limit the extent of brain damage. Radiologic control during the procedure and postoperative follow-up studies are important in the proper management of the patient. It is the radiologist's responsibility to detect malplace-ment, mechanical breakdown, and other causes of shunt failures. Davidoff in 1929 (3) reviewed the approaches to the therapy of hydrocephalus. He traced the treatment back to Hippocrates who is given credit for forming trephine holes in the skull and then puncturing the ventricles. Payr in 1908 used a vascular graft, connecting the longitudinal sinus to the lateral ventricles by an autogenous or homologous vein. Postoperative follow-up is not well documented. Melnic in 1909 used a F-shape vessel and transplanted it to the jugular vein in the neck. His single patient died after the operation (8). Since these early attempts, numerous shunting procedures have been tried. The present-day method for treatment had its origin with Ingraham and his associates in 1948 (5). They studied dogs having obstructed hydrocephalus with shunts to the venous system both in the anesthetized state and while awake. The cerebrospinal fluid flow was away from the ventricles when the animals were anesthetized. Upon awakening, however, the dogs became active and the reversal of flow from increased venous pressure caused the shunts to clot. It was concluded that a unidirection valve system was needed to prevent clotting in the tubing. The three basic shunting systems utilized today are the ventricular-atrial shunts, ventricular-pleural shunts, and ventricular-peritoneal shunts. The peritoneal and pleural shunts are used as temporary measures when intracranial hemorrhage or infection is present. They are later replaced by the more efficient ventricular-atrial shunt (9). The shunting device has a valve that opens at a determined pressure and thus permits drainage of cerebrospinal fluid from the ventricles of the brain to another body compartment. The two popular valve mechanisms used are the Holter valve and the Hakim valve (4). Although they are basically similar in construction, our experience has been chiefly with the Holter valve and its use in ventricular auriculostomies. The Holter valve is composed of a double fish-mouth valve that opens at variable intracranial pressures. At one end of the valve is a catheter that extends into the ventricular system.

MORE COMMENT ON DR. FICK

To the Editor : I have read with much interest Dr. Fick's article in the May, 1964, issue of theArchives of Otolaryngology. The formation of a sheer membrane as described in Meniere's disease reminds me of the sclerocorneal trephine for glaucoma of the eye. In this procedure the trephine hole is covered by a conjunctival flap beneath which the aqueous humor is allowed to leak. It would be interesting for Dr. Fick to supplement his study with pre- and postoperative electronystagmographic records. The case in which he observed the lateral wall of the saccule distended against the footplate when he made a large fenestra is, I believe, the first clinical observation of the basic pathology of Meniere's disease. In connection with the racial incidence of Meniere's disease, we see fewer cases in India than I saw during my residency in the USA and England in 1954 to 1957. The better

A METHOD FOR OBTAINING RABBIT BONE MARROW FOR CHROMOSOME STUDIES.

SummaryA technique for aspirating and preparing bone marrow for chromosome studies without harm or permanent injury to the rabbit is described. In consists of an intra-peritoneal injection of Colcemide at midday, followed in 45 minutes by anesthesia (nem-butal plus local novocain) and bone marrow aspiration by trephine. Aspiration is by an anterior medial puncture on the distal end of the left femur. Samples were obtained from 55 animals, of which none was lost due to the marrow recovery technique. Post-mortem observations indicated that bone regeneration commences within 1 week and is almost complete at 4 weeks. At 5 weeks the trephine hole is almost impossible to locate radio-graphically. This method may well be applied to other small mammals where current techniques require killing the animals.

Brain stem reticular formation influence on convulsions in monkey. Effects in focalized and generalized convulsions.

Introduction A number of papers have discussed the influence of the reticular formation upon cortical epileptic activity. Most of these papers have dealt with the effect of stimulation of the reticular formation; few have studied the effects of chronic lesions of the brain stem reticular formation upon cortical seizures. Because of the reported effect, usually inhibitory, of the reticular formation on cortical seizure activity, a series of experiments has been carried out on monkeys in which the brain stem reticular formation has been destroyed, unilaterally and bilaterally, in order to study the effect upon induced focal and generalized attacks. Methods In 6 monkeys satisfactory experimental preparations have been obtained, but in 1 of these cases anatomical controls are not available, although clinically the animal exhibited the typical syndrome of bilateral reticular lesions (Fig. 1). The monkeys were anesthetized with pentobarbital sodium (Nembutal) administered intravenously, and a trephine hole approximately 1