Sciatic neuralgia associated with a perineural (Tarlov) cyst

Perineural (Tarlov) cysts are rare and are usually asymptomatic and an incidental finding on routine spinal imaging. Presented here is a case of sciatic neuralgia in a 56-year-old patient whose clinical symptoms correlated with a lower lumbar perineural cyst.     

Tarlov Cyst: A diagnostic of exclusion

Tarlov cysts were first described in 1938 as an incidental finding at autopsy. The cysts are usually diagnosed on MRI, which reveals the lesion arising from the sacral nerve root near the dorsal root ganglion. Symptomatic sacral perineural cysts are uncommon and it is recommended to consider Tarlov cyst as a diagnostic of exclusion.We report a case of a patient with voluminous bilateral L5 and S1 Tarlov cyst, and right hip osteonecrosis to increase the awareness in the orthopaedic community.A 57-year-old female, in good health, with chronic low back pain since 20 years, presented suddenly right buttock pain, right inguinal fold pain and low back pain for two months, with inability to walk and to sit down.X-ray of the lumbo-sacral spine revealed asymmetric discopathy L5-S1 and L3-L4. X-ray of the right hip did not reveal anything. We asked for an MRI of the spine and it revealed a voluminous fluid-filled cystic lesion, arising from the first sacral nerve root on both side and measuring 3,3 cm in diameter. The MRI also show a part of the hip and incidentally we discovered an osteonecrosis Ficat 3 of the right femoral head.The patient was taken for a total hip arthroplasty, by anterior approach. Patient appreciated relief of pain immediately after the surgery. The current case show that even if we find a voluminous cyst we always have to eliminate other diagnosis (especially the frequent like osteonecrosis of the femoral head) and mostly in the case of unclear neurological perturbation.     

Presacral mass consisting of a meningocele and a Tarlov cyst: successful surgical treatment based on pathogenic hypothesis

Summary This illustrative case shows a meningocele created by erosion of the sacrum by a perineurial cyst. It is the first report of a large presacral mass consisting of a perineurial cyst and a meningocele simultaneously. We describe a hypothesis for the pathogenesis of this particular constellation of circumstances and present a successful surgical option based on the assumed pathogenesis.     

Treatment of symptomatic simple renal cysts by percutaneous aspiration and ethanol sclerotherapy

OBJECTIVE: To report our experience with the use of 95% ethanol as sclerotherapy for symptomatic simple renal cysts. PATIENTS AND METHODS: Sixty patients with 64 symptomatic simple renal cysts were treated by ultrasonography (US)-guided percutaneous aspiration and injection of 95% ethanol (31 men and 29 women, mean age 46 years, SD 22). The main presentation was renal pain in 34 patients, renal mass in nine, hypertension in 11 and haematuria in six; 24 cysts were on the right, 32 on the left and four bilateral. Patients were evaluated after 1 month and then every 6 months by clinical assessment, US and intravenous urography. Success was defined as complete when there was total ablation of the cyst and partial when there was a recurrence of less than half the original cyst volume with the resolution of symptoms. Failure was defined as the recurrence of more than half of cyst volume and/or persistent symptoms. RESULTS: After aspiration and ethanol sclerotherapy, there was microscopic haematuria in two patients and low-grade fever (<38.3 degrees C) in two, but no major complications. During a mean (range) follow-up of 19 (14-40) months there was complete cyst ablation in 54 cysts and partial resolution in 10. Pain disappeared or was much improved in all patients. After cyst ablation hypertension was well controlled with no medication in all 11 hypertensive patients and haematuria disappeared in all six affected patients. CONCLUSIONS: Ethanol sclerotherapy for symptomatic simple renal cysts is simple, minimally invasive and highly effective. We recommend it as the first therapeutic option in these patients.     

Reversible CSF cyst related to a functioning ventriculo-peritoneal shunt

Summary Although the occurrence of CSF oedema and cyst has been described in presence of a blocked ventriculoperitoneal shunt, especially distal end block, its occurrence in presence of a well functioning shunt has not been described so far. We report a case where a 51-year old lady developed an insidious onset and gradually progressive CSF cyst without any clinical or radiological feature of shunt block over a period of about 2 years. The changes started about 6 months after a course of radiation therapy for an extensive residual supra and infratentorial meningioma. Following surgery, where the cyst was punctured and a new ventricular catheter was inserted, despite well functioning upper and lower end, the cyst gradually disappeared. We review the literature and hypothesize that the radiation-induced changes were responsible for initiation and progression of the cyst.     

Choledochoscopy as a complementary procedure to operative cholangiography in biliary surgery

Six years' experience with the use of the flexible choledochoscope for biliary surgery is reported. One hundred forty-nine patients underwent common bile duct exploration with choledochoscopy as a complementary procedure. Choledochoscopy immediately showed the absence of stones in 37 patients in whom stones were suspected but the results of preexploratory operative cholangiography were negative or equivocal. The remaining 112 patients underwent choledocholithotomy with choledochoscopy. Only two patients (1.3 percent) returned with unsuspected residual stones.Choledochoscopy used as a complementary procedure to operative cholangiography can easily and more accurately clarify suspicious findings in the operative cholangiogram. It avoids the use of blind instrumental exploration of the bile ducts. Impacted stones can be extracted easily under direct vision with the choledochoscope. We believe that the use of choledochoscopy contributed to our low incidence of retained stones.     

Arachnoid cyst of quadrigeminal cistern presenting as trigeminal neuralgia

Summary We describe an extremely rare case of trigeminal neuralgia caused by an arachnoid cyst located in the contralateral cerebellopontine angle.     

Leptomeningeal cyst due to vacuum extraction delivery in a twin infant

Summary A rare case of a leptomeningeal cyst is reported in a twin male neonate delivered using a vacuum extractor, who presented a huge, non-pulsating, oedematous mass overlying the frontal fontanelle after birth. The mass was initially diagnosed as a cephalo haematoma. Ultrasonography indicated intracranial bleeding and a subsequent CT scan revealed an intraparenchymal bleeding above the left frontal horn, combined with a thin, left-sided, subdural haematoma and subarachnoid haemorrhage in the left Sylvian fissure. Apart from a bulging soft and round formation (2 × 2 × 3 cm) next to the anterior fontanel growing since birth, the neurological development of the infant was normal. MRI examination at the age of 7 months revealed that it consisted of a cystic mass (leptomeningeal cyst) connected to the left frontal horn, stretching right through the brain and also penetrating the dura mater. No signs of the perinatal haematomas were observed at this time. Surgical treatment, with fenestration of the cyst into the frontal horn and a watertight duraplasty with a periosteal flap and thrombin glue covered by small bone chips, was performed at 9 months of age. Due to a residual skull bone defect a second cranioplasty with autologous skull bone was performed three and half years later. During a follow-up period of 12 years the neurological and psychological development of the boy has been indistinguishable to that of his twin brother, indicating the satisfactory outcome of the treatment.     

Repeated Percutaneous Aspiration Therapy Prior to Surgery for a Pancreatic Pseudocyst: Report of a Case

(Received for publication on Oct. 7, 1996; accepted on July 8, 1997)     

Rupture of a small middle cerebral artery aneurysm into middle fossa arachnoid cyst presenting as a chronic subdural haematoma

Summary The rupture of an aneurysm into an arachnoid cyst and subdural space is unusual. A 25-year-old man was admitted 2 weeks after having undergone a burr hole drainage for a chronic subdural haematoma elsewhere. An angiogram revealed a small aneurysm at the bifurcation of the middle cerebral artery. The aneurysm was clipped and the cyst communicated with the basal cisterns. To the best of our knowledge, this is the first report of an association of an aneurysm of the middle cerebral artery with an arachnoid cyst presenting as a chronic subdural haematoma. Correspondence: Hasan Kocaeli, Medical Centre, Department of Neurosurgery, University of Cincinnati, 231 Albert Sabin Way, P.O. Box 670515, Cincinnati, OH 45267-0515, USA.     

Rupture of the Achilles tendon treated by a simple operative procedure

A subcutaneous suture technique for repair of closed rupture of the Achilles tendon first reported in 1977 is described again. The use of the technique in Aberdeen is compared with cases treated in plaster during the same 2-year-period. Although the total in the series is only 35, the results appear to indicate that the subcutaneous suture technique improves the power of plantar flexion without significant post-operative complications.     

Tumefactive cyst with a vascular blush as a late complication after combined embolization and stereotactic radiosurgery treatments for a cerebral arteriovenous malformation

Summary Cyst formation is a recognized late complication after stereotactic radiosurgery for cerebral arteriovenous malformations (AVMs). We report on a patient with delayed cyst formation after combined embolization and stereotactic radiosurgery treatments for a cerebral AVM. The true nature of the cyst was complicated by tumefactive magnetic resonance MR imaging characteristics. The tumefactive cyst was associated with an additional imaging finding suggestive of a neoplastic lesion – a ‘blush’ on conventional angiography.     

Spinal intramedullary ependymal cyst: a case report and review of the literature

Summary We report a rare case of spinal intramedullary ependymal cyst in a 44-year-old female and reviewed 12 cases reported in the literature. The patient presented with slowly progressive lower limb paresis. She underwent biopsy of the cyst wall and placement of a cysto-subarachnoid shunt with complete recovery at the follow-up examination 18 months after surgery. This is a benign lesion and appropriate management should be performed at an early stage of the disease.     

Injury to the brachial plexus as a result of diagnostic arteriography

Six cases of brachial plexus injury within the brachial sheath are reported following axillary-brachial arteriography. Direct compression resulted from leakage of arterial blood into the space formed by the fascial sheath. In one, hemorrhage occurred several days after arteriotomy. Early decompression and arteriorrhaphy resulted in restoration of normal function. Permanent nerve damage resulted when surgical decompression was delayed.     

Revascularization in severe ventricular dysfunction (15% ≤ LVEF ≤ 30%): a comparison of bypass grafting and percutaneous intervention

Background

We sought to determine the optimal approach to revascularization of patients with severe left ventricular (LV) dysfunction.

Methods

We conducted a single-center observational study of 117 consecutive patients who had severe LV dysfunction (15% ≤ LV ejection fraction ≤ 30%) and underwent either coronary artery bypass grafting (CABG, n = 69) or percutaneous revascularization (n = 48) between 1992 and 1997.

Results

The CABG group was younger (62 versus 67 years, p = 0.026), and fewer previous bypasses (7% versus 40%, p < 0.0001) and fewer prior percutaneous revascularizations (16% versus 42%, p = 0.0019) were noted. More vessels were revascularized (3 ± 0.8 versus 1.5 ± 0.7, p < 0.0001), and revascularization was more complete by CABG (84% versus 48%, p < 0.0001). Morbidity and mortality at 30 days were similar, and there was no significant difference in 3-year survival (73% versus 67%), although 3-year cardiac event-free survival (52% versus 25%, p = 0.0011) and 3-year target vessel revascularization-free survival (71% versus 41%, p < 0.0001) were significantly better in the CABG group, and LV ejection fraction was significantly improved after CABG. In the subgroup of patients 65 years of age or older and those without proximal left anterior descending coronary artery lesions, significant benefit of CABG in cardiac event-free and target vessel revascularization-free survival disappeared.

Conclusions

We found that in clinically selected patients with severe ventricular dysfunction, CABG compared with percutaneous revascularization achieves more complete revascularization, improved LV function, fewer cardiac events, and fewer target vessel revascularizations, but does not affect mid-term survival. A prospective controlled trial with defined criteria for treatment assignment is warranted to confirm our results regarding the two revascularization strategies in patients with severe LV dysfunction.     

Non-operative treatment of spontaneous spinal epidural hematomas: a review of the literature and a comparison with operative cases

Summary Objective. To identify factors that favour spontaneous recovery in patients who suffered a spontaneous spinal epidural hematoma (SSEH).Methods. The literature was reviewed reguarding non-operative cases of SSEH (SSEH^cons). Sixty-two cases from the literature and 2 of our own cases were collected, focusing on sex, age, medical history, position of the hematoma, segmental distribution and length of the hematoma, diagnostic imaging, neurological condition and outcome. Those data were analysed and compared with the data from a literature review of 474 cases operated on because of a SSEH (SSEH^oper).Results. The mean length of the hematoma was significantly higher in SSEH^cons, compared to SSEH^oper (5.4 versus 4.2 vertebral segments; [standard error of the difference (SED) is 0.38 vertebral segments; 95% confidence limits for the difference are 0.45 to 1.95]). Also after exclusion of patients with coagulopathy, mean length of the hematoma was significantly higher in SSEH^cons (4.7 versus 3.9 vertebral segments [SED is 0.39 vertebral segment; 95% confidence limits for the difference are 0.04 to 1.56]). Neurological signs and symptoms in SSEH^cons were significantly less severe (P<0.005) and diagnosis was based on Magnetic Resonance Imaging (MRI) in the majority of cases (P<0.0005), when compared to SSEH^oper. All other patient characteristics showed no correlation with spontaneous recovery.Conclusion. The recent increase of publications of SSEH^cons has to be explained by the introduction of MRI in daily medical practice. As a result, more patients with a mild or benign clinical course are being diagnosed. In earlier times those patients would have escaped medical attention. The mean length of the hematoma in SSEH^cons appears to be significantly higher compared to SSEH^oper. This suggests that spontaneous regression of neurological symptoms may result from decompression of the neural structures by spreading of the (liquid) hematoma along the spinal epidural space in the early stages after haemorrhage. Based on the present review, there appear to be no factors which promote conservative treatment in SSEH. In the majority of cases with SSEH, the mainstay of treatment will remain surgical decompression of the neural structures and removal of the hematoma. The decision for conservative treatment has to be based on the severity of the neurological deficit and on the clinical course. Retrospectively, the length of the hematoma seems to give a clue to the spontaneous recovery which occurs in some cases of SSEH. Nevertheless, hematoma-length can not be used as a guide to treatment.     

Capsule plication as a protective measure against post-operative intracapsular haematoma formation following trans-sphenoidal removal of pituitary macroadenoma

Summary   Background. Post-operative haematoma and visual deterioration are rare but serious complications after trans-sphenoidal surgery. For more reliable decompression of the optic nerve, we introduce a new technique for volume reduction of the cavity remaining after trans-sphenoidal resection of macroadenomas. Technique. After intracapsular removal of the adenoma, the suprasellar portion of the tumour ‘capsule’ spontaneously prolapsed into the sella turcica. The lowest part of the prolapsed capsule was sutured and/or clipped to reduce the volume of the residual cavity remaining after tumour resection. Findings. A total of 23 patients with macroadenomas extending to suprasellar area had visual symptoms and were treated by trans-sphenoidal surgery. In seven (30%) patients, computerised tomography scans on the first post-operative day demonstrated haematoma formation in the residual cavity. The magnetic resonance imagings on the seventh post-operative day, however, showed approximately 80% reduction in the tumour size. Visual disturbance improved in 20 patients (87%). No patient had post-operative deterioration of visual function. The complications in this series included transient diabetes insipidus in three patients and panhypopituitarism in one patient. Conclusions. Capsule plication is a useful measure for volume reduction of the large residual cavity after trans-sphenoidal surgery for macroadenoma. It may prevent an acute post-operative complication due to intracapsular haematoma, and improve surgical outcome in well selected cases. Correspondence: Masahiko Kitano, M.D., Department of Neurosurgery, Kinki University School of Medicine, 377-2, Ohono-Higashi, Osaka-Sayama, Osaka 589-8511, Japan.     

Penetrating left ventricular stab wound: a method of control during resuscitation and prior to repair

A 34-year-old man with left ventricular stab wounds, suffered cardiac arrest soon after arriving in the Intensive Care Unit from the Accident and Emergency Department. He had cardiac tamponade without elevation of his central venous pressure; this was because of exsanguination into his left hemithorax. Immediate thoracotomy while still in his bed confirmed tamponade and revealed two large left ventricular stab wounds, one anterior and one posterior; the heart was in ventricular fibrillation. As he had already been anoxic for some time, no effort could be made to repair the stab wounds before resuscitating him. It was neccessary to control bleeding from two separate injuries while replacing volume, continuing with intracardiac drugs, internal cardiac massage and internal defibrillation. This was achieved by inserting a Foley catheter into each wound, inflating the balloons, clamping the catheters and having the assistant gently retracting the catheters against each other while the operator continued with the resuscitation. When the circulation was restored, pledgeted horizontal mattress sutures were inserted on either side of each Foley catheter, which was with-drawn immediately before tying the suture. The patient was discharged home 12 days later without any complications.     

Restoration of sensation using a local neurovascular island flap as a primary procedure in extensive pulp loss of the fingertip

A technique using a local composite neurovascular island flap, raised on the volar digital vessels and nerve, is described as a primary procedure for the reconstruction of extensive pulp loss of the fingertip. The results of this technique have been uniformly satisfactory in 8 patients.