Cervico-mediastinal goiter

We analyzed 824 patients treated by thyroidectomy in our Institute from January 1995 to December 2000. We observed the presence of cervicomediastinal goiter in 117 patients (14.9%), 92.7% of whom presented euthyroidism. Sternotomies were performed in 15 patients (10 midline and 5 hemi-clamshell). On the basis of our own experience and the reports in the literature, we analyse the diagnostic and surgical approach to the therapy of cervicomediastinal goiter.     

Symptomatic subacute subdural haematoma following spontaneous acute subdural haematoma

Summary Two patients with non-traumatic acute subdural haematoma were observed, initially without surgical intervention. Eleven days after the onset, each patient developed hemiparesis and an increase in severity of headache. Serial computed tomography scans demonstrated that the initial hyperdense haematomas became hypodense with a definite increase in volume. The term symptomatic subacute subdural haematoma was proposed to properly define this pathological process, which necessitated removal of the haematoma in the subacute stage. The mechanism of increase in the volume of the haematoma is discussed.     

Outcome following acute subdural haematoma

Summary An analysis and long-term follow-up of 136 patients with acute subdural haematoma diagnosed or operated on within 72 hours after injury confirmed the poor outcome: 27 patients (20 percent) made a useful recovery, 13 (10 percent) are severely disabled, and 95 died (70 percent). One patient is still in a vegetative state. The poor outcome in those injuries requiring surgery in the first 24 hours suggests that the term acute subdural haematoma should be limited to this group. Earlier diagnosis and operation on acute subdural haematomas without severe primary brain injury may obviously save a few more patients. However, with very early admissions the number of patients with severe primary brain injury goes up; thus the poor outcome for acute subdural haematoma is likely to remain high.     

Spinal haematoma following epidural analgesia

A patient who developed an epidural haematoma with multifactorial aetiology (bleeding diathesis, ankylosing spondylitis, chronic alcoholism and acute pancreatitis) after epidural analgesia for pain relief is described. Our conclusion is that adequate laboratory screening of blood coagulation, including platelet count, should be carried out in this category of patient before attempted epidural blockade, the risks of which must be weighed against the benefits. The block should be allowed to wear off intermittently and repeated neurological assessment performed if an epidural catheter is used for repeated injections or for a continuous infusion of local anaesthetic. Neuroradiological examination should be carried out promptly if an epidural haematoma is suspected and surgical decompression performed without delay if the diagnosis is confirmed.     

Cervico-mediastinal lymphangioma.

Two cases of cervico-mediastinal lymphangioma ppesenting in adults are reported. In one the lesion originated in the mediastinum and only when advanced showed extension into the neck. The other was associated with a cervical cystic hygroma. Both wwer relieved by one-stage excision. Although they are benign, the tendency of these lesions is to become progressively larger, and to infiltrate between the vital structures in the neck and mediastinum. These features, and the importance of early surgery, are illustrated by the patients we now report.     

Cervico-mediastinal extension of thyroid cancer

A surgical series of 30 cervico-mediastinal thyroid cancer patients operated on has been retrospectively reviewed. Results were compared with those obtained in patients operated on for benign cervico-mediastinal goiter and thyroid cancer confined to cervical region. Of 4688 thyroidectomies performed, 30 patients were operated on for thyroid carcinoma with cervico-mediastinal extension. There were 15 males and 15 females. The mean age was 67 years (range, 21-86 years). Patients with cervico-mediastinal cancer were significantly older than patients with benign cervico-mediastinal goiter (P < 0.0001). Time between onset of first symptoms and surgery was significantly longer in patients with cervico-mediastinal cancer than in those with benign cervico-mediastinal goiter (P < 0.0001) and cervical thyroid cancer. Signs and symptoms at the time of surgery were cervical mass in 28 patients (93%), cervical lymphadenopathy in 20 patients (66%), dyspnea in 21 (70%), dysphagia in 9 (30%), dysphonia in 2 (7%), and venous stasis in 1 (3%). None of the patients was asymptomatic. Total thyroidectomy with functional lymphectomy was performed in 16 cases. Seven of these patients were operated on in 2 stages. In 8 cases the operation was a debulking procedure, and in 6 it was a near-total thyroidectomy. Sternotomy was performed in two cases. A differentiated thyroid cancer was found in 21 patients (70%), medullary in 5 (17%) and undifferentiated in 4 (13%). The incidence of medullary carcinoma was significantly higher compared with cervical cancer (P < 0.008). Postoperative complications were higher than those occurring in benign cervico-mediastinal goiter and similar to those occurring in cervical cancer. The actuarial survival was similar to that of cervical cancer matched for age and sex. This analysis shows that the longer clinical history of goiter is related to its endothoracic development and its neoplastic transformation. This finding should further encourage surgeons to treat any cervico-mediastinal goiter as promptly as possible.     

Management of retroperitoneal haematoma following penetrating trauma

Experience with the management of 106 consecutive patients found to have a retroperitoneal haematoma (RH) at laparotomy for penetrating trauma over a 2-year period is reviewed. Three types of retroperitoneal haematoma are recognized: Type I (central), Type II (flank) and Type III (pelvic). Type I RH was present in 22 patients as a result of injuries to the inferior vena cava (9), the aorta (5), the pancreas and duodenum (5), the portal vein (2), and to both aorta and inferior vena cava (1). Fourteen patients died (63.8 per cent) representing 70 per cent of all deaths in the series. Type II RH was seen in 73 patients. Thirty-two were stable and the perinephric fascia was not opened with no morbidity or mortality. Forty-one were explored: 15 on pre-operative evidence of renal injury which was confirmed at laparotomy. In the remaining 26 a stable haematoma was explored and no significant lesion found. It is considered that in 45 of 73 Type II RH (61.0 per cent) exploration was unnecessary. Five patients died (6.8 per cent). Type III RH was found in 11 patients and was due to iliac vessel injuries. Two patients died. In conclusion Type I and III RH should be routinely explored. Stable Type II RH discovered at laparotomy should be explored selectively based on pre-operative clinical and radiological assessment of renal injury.     

Subperiosteal intraorbital haematoma following minor head trauma

Summary Subperiosteal haematoma of the orbit following minor head trauma is extremely rare. A 5-year-old girl is presented with bilateral proptosis, chemosis, extraocular palsy, and progressive visual loss after minor head trauma. She had no evidence of fracture or abnormality of coagulation. The intraorbital haematoma resulted most probably from the oozings of a subgaleal haemorrhage which entered the subperiosteal space and then dissected over the supraorbital ridge into the orbit.     

A subdural haematoma following 'reverse' bungee jumping

Bungee jumping has been exploited commercially for 13 years and proprietors claim a good safety record. However, published case reports document a wide variety of possible injuries. To this list, we add a report of a subdural haematoma sustained during a variant of the sport, the 'reverse' bungee jump.     

Interhemispheric subdural haematoma following head injury.

A case of interhemispheric subdural haematoma following head injury is reported. The clinical and computerized axial tomographic (CT) features of this unusual complication are described together with the surgical management.     

Human Kluver-Bucy syndrome following acute subdural haematoma

Summary. We present a rare case of complete human Kluver-Bucy syndrome (KBS) following recovery from transtentorial herniation caused by acute subdural haematoma (ASDH). A 17-year-old right-handed high school boy got into stupor within five minutes after 3-rounds of sparing at boxing. Emergency computed tomographic (CT) scan showed right cerebral hemispheric ASDH, which was evacuated following intentional decompressive craniectomy. After recovery of consciousness, he developed emotional changes (placidity with loss of normal fear and anger), psychic blindness, aberrant sexual behaviour, excessive oral tendencies, increased appetite, and hypermetamorphosis in order of mention, which were observed with waxing and waning from 17th to 28th hospital day. Peri-operative CT scaning and magnetic resonance imaging showed lesions of the right temporal lobe and right-dominant orbitofrontal regions including bilateral rectal and medial orbital gyri, and the intact left temporal lobe. Two pathogeneses can be thought of and the whole picture of KBS following ASDH can arise even though one (left in this case) temporal lobe is preserved, 1) in which associated orbitofrontal lesions of the frontal lobes may correlate with occurrence of KBS, or 2) cerebral blood hypoperfusion of both temporal lobes due to increased intracranial pressure and/or compression of both posterior cerebral arteries at the edge of the tentorium cerebelli occurs.     

Two cases of retrovesical haematoma following prostatic biopsy

Prostatic biopsy is a definitive diagnostic method that should be used whenever a prostatic malignancy is suspected. Anatomically it can be done from the transrectal or perineal route. In two methods transrectal ultrasonography can be used as a helper tool. In this paper we present two cases of pelvic haematoma following prostatic biopsy that occasionally cause complications.