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Spontaneous intracranial hypotension (SIH) is a potentially debilitating condition resulting from a low cerebrospinal fluid (CSF) volume secondary to spinal CSF leakage. Characteristic clinical and radiological imaging findings are helpful in diagnosis. Herein, we present and discuss the magnetic resonance imaging (MRI) and CSF flow study of two patients with SIH and no CSF flow within the cerebral aqueduct, which is extremely rare in the literature. [ABSTRACT FROM AUTHOR]

Spontaneous intracranial hemorrhage (ICH) patients are still at risk of postoperative ischemic complications (PICs) after surgery. In addition, the proportion of patients receiving antiplatelet therapy (APT) in ICH patients increased significantly with age. This study aims to evaluate the impact of preoperative antiplatelet therapy on PICs in ICH patients. This is a cohort study that retrospectively analyzed the data of ICH patients who underwent surgical treatment. PICs rate was compared between patients with preoperative ATP and those without preoperative ATP. Univariate and multivariate analyses were conducted to evaluate the impact of preoperative APT on PICs. In addition, Kaplan-Meier method was used for survival analysis and the impact of PICs on patients' postoperative outcomes was evaluated. A total of 216 patients were included in this study. There were 47 patients (21.76%) with preoperative APT; 169 patients (78.24%) without preoperative APT. The incidence of PICs in the APT group was significantly higher when compared with that in the nAPT group (36.17% vs. 20.71%, p = 0.028＜0.05). Furthermore, significant differences were both observed in multivariate analysis (p = 0.035＜0.05) and survival analysis (log rank χ2 = 5.415, p = 0.020＜0.05). However, there was no significant difference between the outcomes of patients suffering from PICs and that of patients not suffering from PICs (p = 0.377 > 0.05). In conclusion, preoperative APT may be a risk factor for PICs in ICH patients undergoing surgical treatment significantly. [ABSTRACT FROM AUTHOR]

Background: Percutaneous balloon compression is a safe and effective treatment for trigeminal neuralgia. Current technique consists of penetrating the foramen ovale using a sharp 14G needle with a stylet. Difficulty of cannulation of the foramen ovale, failures of cannulation and major neurovascular complications of the procedure, although rare, may be due to the relatively large caliber of this needle and its sharp tip. Objective: To present a novel technique to facilitate and make the cannulation of the foramen ovale with a 14G cannula safer. Methods: A rigid blunt-tip guide of 1.2 or 1.5 mm is used to penetrate the foramen ovale under lateral fluoroscopic control. Once the guide enters the foramen it is advanced further to the clival line, and a 14G cannula is then advanced over the guide to engage the foramen, at which point the guide is withdrawn and replaced with the balloon catheter. Results: The technique was employed to deliver a 4F balloon catheter to Meckel's cave successfully in 500 consecutive procedures performed on 416 trigeminal neuralgia patients. None of the patients had neurovascular complications like facial hematoma, arterial injury, carotid-cavernous fistula or cranial nerve palsies. Conclusion: A novel technique for cannulation of the foramen ovale is described. The use of blunt tip guides of smaller diameters instead of sharp 14G needles considerably facilitated cannulation of the foramen ovale and enabled cannulation in all cases. Absence of complications of cannulation such as facial hematoma, carotid-cavernous fistula or intracranial hemorrhage in this series of patients suggests that the technique may be safer than the use of conventional sharp tipped 14G needles in terms of avoiding neurovascular complications. [ABSTRACT FROM AUTHOR]

Primary Spinal tumors presenting as increased intracranial pressure is a rare and intradural extramedullary (IDEM) spinal schwannoma with unique presentation of pseudotumour cerebri (PTC) is extremely rare. Here, we describe a case of 48 years old male patient who presented to us with six months' history of headache and visual disturbances and was found to have bilateral papilledema. CT scan of brain was normal and CSF opening pressure on Lumbar puncture (LP) was 30 cm of H2O with raised protein level. His headache and visual symptoms settled down after LP (Lumbo-peritoneal) shunt was performed. Three days postoperatively, patient complained of hypoesthesia and weakness of left leg that became an established complain after 2 weeks. A Lumbosacral MRI was performed with concerns of any postoperative complications of LP Shunt, which revealed IDEM spinal tumour at D11-D12 level. Patient underwent second surgery for excision of tumor. We reviewed the relevant literatures and discuss the possible mechanism of such atypical presentation of spinal tumors. [ABSTRACT FROM AUTHOR]

Interdural hematoma (IDH) is an extremely rare hemorrhage between the outer periosteal dura mater and the inner meningeal dura mater. There are 8 cases of convexity IDH reported previously but none of them were acute post traumatic one. We report the case of a patient with an initial diagnosis of acute epidural hematoma (EDH) that was eventually revealed to be an acute convexity IDH. A 57-year-old man presented to the emergency department with a complaint of falling from 2 meters. Imaging findings revealed an expanding intracranial hematoma with a linear skull fracture extending to sagittal suture, which was mistaken as an EDH. Emergent surgical evacuation was performed; the hematoma was lodged between two dural layers. This is the first case of acute convexity IDH following trauma that has been reported. In chronic and sub-acute hematomas MRI scans could be very useful, but in acute cases under emergent circumstances, CT scan cannot make a proper differentiation between an EDH and IDH. IDH should be considered during craniotomy when extradural findings do not explain the CT scan findings. This case showed a linear skull fracture expanding to the sagittal suture, and this can be a possible explanation for IDH formation. Surgical evacuation of the hematoma without inner nor outer layer resection and leaving the outer layer open, to connect the interdural space to epidural space was first described in this report. [ABSTRACT FROM AUTHOR]

Remote traumatic intracranial haemorrhage (RTIH) may develop after neurosurgery. Recognition of the risk factors for RTIH before surgery might be of great value. The purpose of this study was to verify if the fibrin/fibrinogen degradation product (FDP) value may be a risk factor for RTIH. This was a retrospective study of the data of 56 patients with traumatic intracranial hematomas shown on initial computed tomography (CT) who were treated with craniotomy or decompressive craniectomy and underwent a follow-up CT at a single centre over a period of approximately 10.5 years. We divided the patients into 2 groups: those who developed RTIH (Positive: P-group) and those who did not (Negative: N-group). We compared the 2 groups in terms of not only the laboratory data before surgery, but also patient age, sex, antiplatelet/antithrombotic medications received, cause of injury, and GCS score on arrival. RTIH was observed in 22 patients (P-group, 39.3%). The FDP value was the only significant risk factor identified in this study (p = 0.00076). The cut-off value was estimated on the basis of the area under the receiver operating characteristic (ROC) curve. The cut-off FDP value was 120 µg/mL (63.6% sensitivity and 85.3% specificity). FDP levels over 120 µg/mL were determined to be a risk factor for progressive RTIH after neurosurgery. We suggest the FDP level be checked before surgery for traumatic intracranial haemorrhage and follow-up CT be done as soon as possible after the surgery if the serum FDP level is over 120 µg/mL. [ABSTRACT FROM AUTHOR]

This letter to the editor responds to an article on unilateral chronic subdural hematoma due to spontaneous intracranial hypotension. The authors propose that asymmetric cranial morphology and transtentorial herniation are risk factors for this condition. However, the letter suggests an alternative mechanism involving localized failure in the cerebral venous system and inflammation as key factors in the formation of chronic subdural hematoma. The authors recommend evaluating previous conditions that could trigger a failure of the cerebral vascular system and consider the potential role of inflammatory mediators in the development of unilateral hematoma. [Extracted from the article]

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. A subset of patients with CSDH may exhibit underlying spontaneous intracranial hypotension (SIH). Bilateral CSDH has a causal relationship with SIH, but there is no known causal relationship between unilateral CSDH and SIH. Case description: We encountered four cases of unilateral CSDH due to SIH. The patients' age ranged between 44 and 64 years; there were three males and one female. All patients presented with headache as their initial symptom, and then became comatose. Computed tomography demonstrated unilateral CSDH and transtentorial herniation in all patients. Treatments were emergency epidural blood patch (EBP) and evacuation of CSDH. The site of cerebrospinal fluid leak could not be identified in three patients; therefore, EBP was performed at upper and lower spine. All patients recovered from SIH; however, one patient experienced poor outcome due to Duret hemorrhage and ischemic complications of transtentorial herniation. Cranial asymmetry was present in all four patients, and unilateral CSDH was located on the side of the most curved cranial convexity. Conclusions: Unilateral CSDH, asymmetric cranial morphology, and transtentorial herniation in relatively young patients may indicate underlying SIH. [ABSTRACT FROM AUTHOR]

Introduction: Neurosurgical residency training is costly, with expenses largely borne by the academic institutions that train residents. One expense is increased operative duration, which leads to poorer patient outcomes. Although other studies have assessed the effect of one resident assisting, none have investigated two residents; thus, we sought to investigate if two residents versus one scrubbed-in impacted operative time, estimated blood loss (EBL), and length-of-stay (LOS). Methods: In this retrospective review of patients who underwent a neurosurgical procedure involving one or two residents between January 2013 and April 2016, we performed multivariable linear regression to determine if there was an association between resident participation and case length, operating room time, EBL, and LOS. We also included patient demographics, attending surgeon, day of the week, start time, pre-operative LOS, procedure performed, and other variables in our model. Only procedures performed at least 40 times during the study period were analyzed. Results: Of 860 procedures that met study criteria, 492 operations were one of six procedures performed at least 40 times, which were anterior cervical discectomy and fusion, cerebrospinal fluid (CSF) shunt insertion, CSF shunt revision, lumbar laminectomy, intracranial hematoma evacuation, and non-skull base, supratentorial parenchymal brain tumor resection. An additional resident was associated with a 35.1-min decrease (p =.01) in operative duration for lumbar laminectomies. However, for intracranial hematoma evacuations, an extra resident was associated with a 24.1 min increase (p =.03) in procedural length. There were no significant differences observed in the other four surgeries. Conclusion: An additional resident may lengthen duration of intracranial hematoma evacuations. However, two residents scrubbed-in were associated with decreased lumbar laminectomy duration. Overall, an extra resident does not increase procedural duration, total operating room utilization, EBL, or post-operative LOS. Allowing two residents to scrub in may be a safe and cost-effective method of educating neurosurgical residents. [ABSTRACT FROM AUTHOR]

Background: Pneumocephalus is a common finding after burr-hole drainage of chronic subdural hematoma (CSDH). Its effects have not been specifically studied. Methods: A retrospective analysis was performed in 140 patients with CSDH with single burr-hole drainage. The pre- and postoperative volumes of intracranial hematoma and the postoperative volume of pneumocephalus were calculated and analyzed with their relationships with Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) scores. Results: The preoperative hematoma volume and the patient ages are positively correlated with the 1-day postoperative pneumocephalus volume (p < 0.001, p < 0.01). There is no correlation between postoperative pneumocephalus volume and GCS/GOS scores (p > 0.05) and there is no difference of GCS/GOS scores or CSDH recurrence rate between patients with and without pneumocephalus (p > 0.05). The age and the volume of 1-day postoperative pneumocephalus are positively correlated with the absorbing rate of pneumocephalus (p < 0.01, p < 0.001). Conclusions: The pneumocephalus at a certain range has no effect on the prognosis of patients with CSDH and requires no specific intervention due to its self-absorbing capacity in the normal progress after surgery. No correlation between postoperative pneumocephalus volume and GCS/GOS scores. No difference of GCS/GOS or recurrence between patients with pneumocephalus or not. Pneumocephalus at certain range has no effect on the prognosis of patients. [ABSTRACT FROM AUTHOR]

Symmetric peripheral gangrene is a rare but devastating complication, scarcely reported after brain surgery. We present a case of symmetric peripheral gangrene shortly after brain surgery of intracranial hematoma removal and aneurysm clipping. [ABSTRACT FROM AUTHOR]

Purpose: To determine the sonographic criteria for diagnosis of fetal intracranial hemorrhage (ICH), using both gray scale ultrasound, and tomographic ultrasound imaging (TUI).Materials and Methods: A prospective multicenter study, recruiting patients at risk of fetal ICH over four years. All cases with fetal ICH had serial ultrasound assessments, including TUI, fetal and postnatal MRIs.Results: Twenty-one patients were diagnosed with fetal ICH, two cases had extracerebral (subdural) hemorrhage, 16 cases had intracerebral (intraventricular) hemorrhage and three cases had combined hemorrhage. The mean gestational age at which they were diagnosed was 29.8 ± 5.2 weeks. Seventy-six percent of cases had no identifiable risk factors. IUGR was associated with 57.9% of cases. Using grey scale ultrasound, we demonstrated clear cut sonographic criteria for diagnosis of fetal ICH. TUI enabled us to detect some midline cerebral lesions not detected by grey scale 2D ultrasound alone. Fetal and postnatal MRI confirmed those findings.Conclusion: Ultrasonography can be used in the detection, classification and monitoring the progression of various types of ICH. TUI is an additional diagnostic tool that might help to detect the exact size, and extent of those lesions. Fetal MRI is not superior, but might aid in the diagnosis. [ABSTRACT FROM AUTHOR]

Objective: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children. Methods: Retrospective case series from the University of Wisconsin – Madison and Medical College of Wisconsin. Results: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele. Conclusion: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments. [ABSTRACT FROM PUBLISHER]

Stroke is a leading cause of mortality and acquired disability; however, there has been no comprehensive comparison of co-morbid risk factors between different stroke subtypes. The aim of this study was to compare risk factors and mortality for subdural haematoma (SDH), subarachnoid haemorrhage (SAH) and ischaemic and haemorrhagic stroke. We compiled a database of all patients admitted with these conditions to a large teaching hospital in Birmingham, United Kingdom during the period 2000-2007 using the International Classification of Disease (ICD) 10th revision codes. Generalised linear models were constructed to calculate relative risks (RRs) associated with co-morbidities. In total, 4804 patients were admitted with diagnoses of SDH (1004), SAH (807), ischaemic stroke (2579) and haemorrhagic stroke (414). Patients with SDH were less likely to have pneumonia (0.492, 95% CI, 0.330-0.734; p < 0.001), whereas alcohol abuse (4.21, 95% CI, 2.82-6.28; p < 0.001) was more common. In SAH, ischaemic heart disease (0.56, 95% CI, 0.40-0.79; p < 0.001) was less common. As expected, a range of cardiovascular risk factors were associated with ischaemic stroke. Epilepsy was positively associated with ischaemic stroke (1.94, 95% CI, 1.36-2.76; p < 0.001), indicating a role for targeted primary prevention in patients with epilepsy. Five-year survival was lower in ischaemic and haemorrhagic strokes (41% and 40% respectively, vs. 73% in SDH and 64% in SAH; p < 0.001). These findings may guide clinical risk stratification, and improve the prognostic information given to patients. [ABSTRACT FROM AUTHOR]

Post-operative haematoma is a well-known complication following the intracranial surgery, the surgical site itself being the most frequent and usually results from inadequate haemostasis. Remote site intracranial haemorrhage, that is, haemorrhage occurring at a distant site from the site of craniotomy, is relatively rare and may occasionally cause significant morbidity or even mortality. Authors report a clinical series of five patients who developed remote site haemorrhage following intracranial surgery. Out of 2500 cranial surgeries performed at the authors' institute in the year 2010, only five patients developed this complication (0.002%). One of these patients developed infratentorial haematoma following supratentorial surgery and one patient developed supratentorial haematoma following infratentorial surgery. All the patients were diagnosed by CT scan in the post-operative period. Four patients were operated and made a good recovery while one patient with cerebellar haematoma rapidly deteriorated and developed brain death and hence was not operated. The pertinent literature is reviewed regarding pathophysiology and management of this rare condition. [ABSTRACT FROM AUTHOR]

Purpose. Intracranial hemangiopericytomas (HPCs) are rare, and they have a tendency for local recurrence and metastases. The purpose of this study was to evaluate the relationship between CT perfusion (CTP) parameters and microvessel density (MVD) of HPCs and compare CTP parameters in parenchyma and peritumoral edema of HPCs. Materials and methods. The study was approved by the ethics committee, and written informed consent was obtained. Ten patients with HPCs and peritumoral edema, confirmed by pathological results, received 64-slice CT perfusion imaging before operation. To evaluate vascular attenuation of tumoral parenchyma, we immunostained the specimen sections for CD-34, measured the integrated optical density of all the positive stained CD-34 cells in the microscopic field, and calculated its ratio to total area of field as MVD. Perfusion analysis was calculated using the Patlak method. Using a 1-cm distance from the outer enhancing tumor margin as a boundary, the peritumoral edema was divided into an immediate and a distant part. The quantitative CTP parameters, including cerebral blood volume (CBV), permeability-surface area product (PS) of parenchyma, and immediate and distant peritumoral edemas, were compared. CBV and PS in parenchyma and immediate and distant peritumoral edemas of HPCs were also compared to their respective contralateral normal white matter. The correlations between MVD, CBV, and PS of tumoral parenchyma were analyzed. Results. Positive correlations existed between CBV and MVD, PS and MVD ( P < 0.05) respectively in the 10 patients. Furthermore, the values of CBV and PS in parenchyma of HPCs were significantly higher than those of the contralateral normal white matter and peritumoral edema ( P < 0.05). The value of CBV in peritumoral edema of HPCs were lower than that of contralateral normal white matter ( P < 0.05), while the value of PS in immediate and distant peritumoral edemas of HPCs were not significantly difference with that of contralateral normal white matter ( P > 0.05). Finally, the values of CBV and PS did not show a significant difference between immediate and distant peritumoral edemas. Conclusions. CT perfusion imaging, especially determination of maximal CBV and corresponding PS values in the parenchyma, may be a useful and non-invasive technique for the preoperative evaluation of hemodynamic features of HPCs with peritumoral edema. CBV of peritumoral edema indicate that HPCs have a possibility of infiltration, this need further radiological-pathological research. [ABSTRACT FROM AUTHOR]

Purpose. We report on 17 patients with traumatic intra-cerebellar haematomas. Methods. We retrospectively reviewed patients' clinical and radiological findings, management criteria and outcomes. Results. Ten patients had poor outcomes. Glasgow Coma Scale (GCS) score at admission was significantly higher in the favourable outcome group than in the poor outcome group ( p == 0.010). The haematoma volume was significantly smaller in the favourable outcome group than in the poor outcome group ( p == 0.025). There were also significant differences between the two groups in terms of types of haematoma location, the status of the brainstem cisterns, the status of the fourth ventricle, and the presence of associated subarachnoid haemorrhage (SAH) ( p == 0.035, 0.002, 0.010, 0.003, respectively). Conclusions. The factors correlated with outcome were GCS score, the status of the brainstem cisterns and the fourth ventricle, the presence of associated SAH, haematoma volume and haematoma location. Further studies are needed to investigate the factors relevant to the management of traumatic intra-cerebellar haematomas. [ABSTRACT FROM AUTHOR]

Objective: To observe the effect of minimally invasive surgery for cerebral hematoma evacuation in different stages on motor evoked potential (MEP) and thrombin in dog model of intracranial hemorrhage. Methods: Twenty dogs were selected to prepare the intracranial hemorrhage model, which were randomly divided into 6, 12, 18 and 24 hour groups, respectively. The animals in each group underwent a minimally invasive surgery to evacuate the cerebral hematoma after the models were prepared. Before and after procedures, Purdy score, MEP and thrombin in hematoma region were determined and compared. Results: Significant decreases in Purdy score, latency of MEP and thrombin expression were observed in 6 and 12 hour groups as compared with the 18 and 24 hour groups (p<0·01). Discussion: In the present experiment, we established a dog model of intracranial hemorrhage, which was minimally invasive, easy to operate, highly repeated, simulating the pathological and physiological changes of clinical hypertensive intracranial hemorrhage. Both the latency of MEP and the expression of thrombin decreased after evacuation of intracranial hematoma in early stages by minimally invasive procedures, indicating that minimally invasive procedures for cerebral hematoma in ultra-early and early stages might be more effective to limit brain injury and decrease the latency of MEP and thrombin expression. [ABSTRACT FROM AUTHOR]

The neuropsychological outcome and Health Related Quality of Life (HRQOL) after SAH have been largely believed to be unrelated to the location of the ruptured aneurysm. This notion needs verification due to the contemporary availability of more sensitive neuropsychological test batteries and more recent clinical observations of deviant behaviour after SAH. To this end, we compared patients with ruptured aneurysms on respectively the anterior communicating artery (ACoA) (n = 24) or middle cerebral artery (MCA) (n = 22). All patients underwent an extensive neuropsychological examination, clinical interview and answered questionnaires 12 months after SAH. We found mild to moderate discrepancies from population norm in test scores on a number of areas of cognitive functioning in both patient groups, with a consistent, but statistically non-significant trend towards better functioning in MCA patients despite of the fact that patients with ruptured MCA aneurysms were initially in a poorer clinical condition and more often had intracranial haematomas. We observed slight reductions in executive functions, on the first conditions on the Delis-Kaplan Executive Functioning System (D-KEFS) tests, and some measures of memory functions in the ACoA patients. ACoA patients seemed to have problems with initiation of problem solving behaviour. None of the patient groups scored for apathy and depression. Some measures of HRQOL were equally reduced as compared to the population norm in both groups. ACoA patients remained longer on sick-leave compared to MCA patients. [ABSTRACT FROM AUTHOR]

Neurosurgical registrars are frequently called upon by A&E staff and physicians to interpret emergency head CT (computed tomography) scans out of hours. This appears to reflect the reduced threshold for scanning patients and the nonavailability of a radiologist to report these scans. This study was undertaken to assess the safety of such practices. Five neurosurgical registrars, blinded to each other and to the radiology reports, interpreted 50 consecutive emergency head CT scans (both trauma and nontrauma) from the hospital's imaging system as a pilot study. These were initially graded as normal or abnormal. Abnormal scans were assessed for the presence of an intracranial bleed, pneumocephalus, skull fractures, cerebral contusions, mass effect, midline shift, ischaemia or hydrocephalus. The agreement of the observers' recordings with the report issued or approved by a consultant radiologist was evaluated using SPSS™ Version 13.0. Four of the five registrars assessed a further 150 scans in a similar manner to complete the study. There was a good general agreement between the formal reports and the neurosurgical registrars' identification of normal scans (average Kappa 0.79). The radiology reports and the registrars also agreed well on the presence or absence of intracranial blood, contusions and pneumocephalus (Kappa value > 0.70). The agreement was poorer for ischaemia, mass lesions (other than intracranial haematomas), grey white differentiation, evidence of raised intracranial pressure and midline shift (Kappa < 0.5). Neurosurgical registrars compared well with radiologists when it came to assessing emergency head CT scans as normal or detecting a surgical lesion. The agreement was poorer on subtle abnormalities. The practice of neurosurgical registrars informally 'reporting' on emergency head CT scans cannot be recommended. [ABSTRACT FROM AUTHOR]

Fetomaternal alloimmune thrombocytopenia (FMAIT) occurs when maternal antibodies are formed to fetal platelet antigens, leading to thrombocytopenia and hemorrhagic complications. The diagnosis is frequently made only after a major hemorrhagic event has occurred during a pregnancy. Identifying patients at risk remains difficult, and the optimal treatment regimen remains to be determined. [ABSTRACT FROM AUTHOR]

We describe a 15-year-old boy who developed isolated bilateral abducens nerve palsies immediately following a motor vehicle accident and who was found to have a pre-pontine extra-axial hematoma. We review the literature on isolated bilateral traumatic abducens palsies and discuss the alternate mechanisms for this injury. [ABSTRACT FROM AUTHOR]

Introduction: Successful reperfusion at the epicardial level is not always accompanied by reperfusion of the microvasculature. Therapies targeted against ‘no‐flow’ are often employed in patients receiving primary percutaneous coronary intervention (pPCI) after acute myocardial infarction. Hypothesis: Abciximab as adjunctive to pPCI will improve ST‐segment resolution used as a surrogate for optimal microvascular reperfusion, and improve prognosis. Methods: In the DANAMI‐2 trial 309/790 (39%) patients treated with pPCI received abciximab at physician discretion. ΣST‐segment elevation at baseline, 90 min, 4 h, 12 h, 24 h after pPCI and at discharge was measured and ST‐segment resolution grouped as: Complete (&NotGreaterSlantEqual;70 %); Partial (&NotGreaterSlantEqual;30 to<70%); No (<30%). Clinical endpoints were death, re‐infarction and disabling stroke. Results: Abciximab prescription varied from 24.4–60.3% in the different hospitals. Patients receiving abciximab had a higher risk profile. ST‐segment resolution at 90 min and 24 h was identical in the two groups, but at 4 h and 12 h partial ST‐segment resolution was more pronounced in patients receiving abciximab (P = 0.001, P = 0.026). In a multivariate analysis, adjusting for baseline differences abciximab was associated with improved partial ST‐segment resolution at 12 h. Patients treated with abciximab had no re‐infarction at 30 days (0% versus 2.8%, P = 0.003), but increased disabling stroke rate (2.3% versus 0.4%; P = 0.019) driven by cerebral infarctions, and not intracranial hemorrhage. There were no differences in death rates. Conclusions: In the DANAMI‐2 trial with no age limit, the decreased re‐infarction rates in patients receiving abciximab was offset by increased disabling stroke rates. Abciximab in conjunction with pPCI is associated with more pronounced partial ST‐segment resolution after 4 h to 12 h suggesting improved microvascular reperfusion. [ABSTRACT FROM AUTHOR]

Objectives: This study assesses the benefits of adapting minimal invasive techniques (MIT) to selected patients with spontaneous supratentorial intracerebral hematomas (SSICHs). Methods: The study compares the post-operative residual clot volume and clinical outcome of 89 selected, MIT evacuated SSICH-patients to those of 138 unselected cases operated in our department. Selection criteria includes patient age, early admission and MIT treatment. MIT treatment included: 28 patients with deep SSICHs smaller than 30 cm3 associated with intraventricular bleeding who underwent neuronavigation-guided stereotactic catheter lysis, 37 patients with deep hematomas larger than 30 cm3 and 24 patients with a lobar hemorrhage compressing eloquent regions who underwent microsurgical (endoscopic or neuronavigation assisted) clot aspiration. Results: In eight (9%) of the patients in the MIT group, the CT scan control showed a residual clot smaller than 30% of the initial hemorrhage. The neurological condition 3 months later revealed 24 (26.9%) of these patients having a severe disability and 46 (51.6%) patients independent or slightly disabled. Nineteen patients (21.9%) died or remained vegetative. In the control group, 48 (34.7%) cases showed residual clots (<30%). Sixty-two (44.9%) patients of this group were severely disabled and only 40 (28.9%) were independent. Thirty-six (26%) patients died or were vegetative. There was a p<0.001 significant difference in volume of residual clots as well as p<0.01 for the outcome between the two groups. Conclusions: Adapting minimally invasive techniques to case selection improves the effectiveness of clot removal and the outcome of the patients with SSICHs. [ABSTRACT FROM AUTHOR]

Objectives: The selection of patients and treatment criteria for acute hydrocephalus and intracranial pressure (ICP) after intracranial hemorrhage remains unclear. In general neurosurgical practice, there is a tendency to use external ventricular drainage (EVD) for the patients. This study was undertaken to analyse the complications and efficiency of the different treatment modalities. Methods: The effects, complications and outcome of ventricular drainage on high ICP and hydrocephalus were analysed retrospectively in 109 patients with intracranial hemorrhage. All the patients were assessed using the Glasgow Coma Scale, computed tomography and ICP monitoring. We excluded patients over the GCS of 8. All patients underwent a procedure for ICP monitoring plus ventricular cerebrospinal fluid (CSF) drainage. Sixty-one patients were managed with one (single) EVD system; 12 patients needed two EVD systems consecutively, while 23 patients underwent an EVD procedure followed by permanent ventriculoperitoneal (VP) shunt insertion. Thirteen patients were treated only by VP shunt for ventricular drainage. The infection rate and outcome 9 months after hemorrhage were analysed. Results: The infection rates were 8.1% in the one-EVD group, 33.3% in the two-EVD group (one EVD versus two EVD, p<0.05), 8.6% in the EVD-VP group and 7.7% in the VP shunt group. The mortality rates were 73.7% in the one-EVD group, 83.8% in the two-EVD group, 47.8% (p<0.05) in the EVD-VP group and 53.8% (p<0.01) in the VP shunt group. Discussion: This study indicates that single and short-term use of EVD and/or early VP shunting are associated with a low risk of infection. Furthermore, early VP shunting may protect the brain from the irregular control of intracranial hypertension and may allow more time for resolution of CSF circulation and significantly lowers the mortality rates. [ABSTRACT FROM AUTHOR]

A detailed neuropathological study of patients identified clinically after head injury as either severely disabled (SD, n &ThickSpace;=&ThickSpace;30) or vegetative (VS, n &ThickSpace;=&ThickSpace;35) has been carried out to determine the nature and frequency of the various pathologies that form the basis of these clinical states. Patients who were SD were older (SD median 49.5 yrs vs. VS median 38 yrs, p &ThickSpace;=&ThickSpace;.04), more likely to have a lucid interval (SD 31% vs. VS 9%, p &ThickSpace;=&ThickSpace;.03), and to have had an acute intracranial haematoma (SD 70% vs. VS 26%, p &ThickSpace;<&ThickSpace;.001). SD patients less often had severe, Grades (2 or 3) of traumatic diffuse axonal injury (SD 30% vs. VS 71%, p &ThickSpace;=&ThickSpace;.001) and less often had thalamic damage (SD 37% vs. VS 80%, p &ThickSpace;<&ThickSpace;.001). Similar features of both focal and diffuse damage were present in some SD and VS cases with both groups having considerable damage to white matter and to the thalamus. It is concluded that the principal structural basis of both SD and VS is diffuse traumatic axonal injury (DAI) with widespread damage to white matter and changes in the thalami. However, both ischaemic brain damage and the vascular complications of raised intracranial pressure contributed to the clinical signs and symptoms. [ABSTRACT FROM AUTHOR]

Primary sarcomas of the central nervous system and their coincidence with a subdural haematoma are each rare. We describe an unusual case of unsuspected dural spreading of a recurrent spindle cell sarcoma concealed in a chronic subdural haematoma, which occurred months after microsurgical resection and external radiation of a temporal parenchymatous sarcoma. [ABSTRACT FROM AUTHOR]

A 33-year-old man presented with a history of fits and on initial investigation was suspected of having a left frontal parafalcine meningioma. Initial surgical procedure to excise the lesion had to be abandoned owing to the extreme vascularity of the lesion. Histology revealed it to be a haemangioendothelioma. At a second operation the tumour was completely removed. The histology of this rather uncommon tumour is discussed and the literature is reviewed. [ABSTRACT FROM AUTHOR]

Postoperative intracranial haematoma is a serious complication of intracranial surgery with a mortality rate of around 30%. There have been reports implicating abrupt rises of blood pressure during the last stages or immediately after the procedure, in the production of the clot.This prospective study examined this hypothesis. Over the last 7 years, 526 consecutive patients underwent craniotomy under a strict anaesthesiological protocol based on deep opioid analgesia which virtually eliminated any acute elevations of the arterial pressure during and immediately after craniotomy. Emergence from anaesthesia was delayed for an average of 11 2-2 h following the procedure. Postoperative CT was obtained in every patient.There have been no cases of postoperative clot formation in this series of patients. The results of the study suggest that postoperative haematoma is probably an avoidable complication of intracranial surgery. [ABSTRACT FROM AUTHOR]

Cerebral developmental venous anomalies (DVAs) very rarely cause massive haematoma, but should be included in the differential diagnosis of atypical massive intracerebral haematoma (ICH). We describe a case of massive ICH caused only by a DVA and successfully treated by haematoma evacuation with surgical resection of the DVA. [ABSTRACT FROM AUTHOR]

In cases of intracerebral haematoma associated with developmental venous anomalies (DVAs), there is usually an associated cavernoma, which is thought to be the source of haemorrhage. Only a few cases have been reported in the literature where an intracerebral haemotoma has been caused by a DVA without an associated cavernoma. In this report we describe a case with a massive haematoma due to venous angioma alone. [ABSTRACT FROM AUTHOR]

Urgent CT scanning of critically ill neurosurgical patients is costly, labour intensive and associated with some risk. A study of urgent postoperative CT scans was carried out to assess the proportion that changed patient management. A further study evaluated the accuracy of predicting a haematoma. A retrospective analysis was carried out over a 6-month period of all scans performed within 48 h of craniotomy. This was followed by a prospective comparison between the surgeon's estimate of the chance of a haematoma on the scan and the scan result. Of 184 patient undergoing craniotomy, 40 patients (22%) were scanned within 48 h. Five patients were re-operated for haematoma formation. Prospective assessment showed that surgeons consistently over-estimated the risk at haematoma (mean prescan estimate 63%, actual risk 8%, p = 2.5 × 10[sup -12]). Less than 1 in 10 postoperative scans show a neurosurgical target. Other changes in management following scanning were slight. [ABSTRACT FROM AUTHOR]

Intracranial epithelioid hemangioendothelioma (EH) is a rare neoplasm in the central nervous system. The authors describe a case of EH arising from the tentorium in a 57-year-old woman. A review of the literature showed that this was the first case report of computed tomographic angiography findings of EH. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Remote site haemorrhage after intracranial surgery" that was published in the previous issue.

The article focuses on acute bleeding into the outer dural membrane space after burr hole craniotomy for chronic subdural hemorrhage. There are reports of unexpected postoperative complications, such as acute epidural hemorrhage, acute chronic subdural hemorrhage, intracranial hematoma, tension pneumocephalus and ischaemic cerebral infarction after twist drill or burr hole craniotomy. The twist drill or burr hole craniotomy with closed system drainage was suggested by T. M. Markwalder in 1981.