Role of skull radiography in the initial evaluation of minor head injury: A retrospective study

Summary The use of skull radiography in the initial evaluation of minor head injured patients is controversial. In an attempt to evaluate its benefits, a retrospective study of 566 cases subjected to skull radiography following close minor head trauma (Glasgow Coma Scale 13–15), is presented.A skull fracture (linear vault, depressed or base of skull) was present in 64 (11%) cases. Only three (5%) who were found to have a skull fracture on skull radiography developed an intracranial injury which required surgery.Intracranial injuries developed in 19 (3%) cases and were followed by surgery in six (32%). All, except for one case, had a decreased level of consciousness and a Glasgow Coma Scale less than 15, few had focal neurological deficits. Management had not been altered by the results of skull radiography in any of the cases.We concluded that skull radiographs are unnecessary for the decision process in closed minor head injury because management decisions are based primarily on a careful neurological examination. When intracranial injuries are a concern, a CT scan should be obtained.     

Aneurysmal bone cysts in the cranial vault and base of skull

Three cases of aneurysmal bone cyst of the skull are reported. The localization in the base of the skull (two cases) is extremely rare and simulates a space-occupying intracerebral lesion. The clinical and microscopic findings, and their significance for the differential diagnosis from malignant brain tumors, are described.     

颅骨缺损86例修补手术体会

目的:总结颅骨修补手术治疗的经验体会,探讨如何进一步提高手术的成功率及防治并发症。方法:回顾性分析我科自2006年3月～2011年12月应用钛网修补颅骨缺损86例患者的临床资料。结果:79例术后12天内痊愈出院,7例出现并发症包括:皮下积液4例、钛网外露3例而延迟出院。随访3～24月,大多数病人术前缺损综合征基本消失,其中2例癫痫发作明显缓解,1例肢体瘫痪明显改善。但有1例患者术后出现癫痫发作,2例出现疼痛,3例对额部塑形不够满意。结论:手术者的思维与技巧是修补术成功的关键,通过术中的细心、耐心操作和术后的正确处理,可以减少并发症的发生,提高成功率。     

Aneurysmal bone cyst of the cranial base treated by partial resection and calcitonin injection. A case report

STUDY DESIGN: First published report of a cranial aneurysmal bone cyst (ABC) treated successfully with intralesional injection of calcitonin. OBJECTIVES: To describe a safe and effective treatment method for ABCs of the cranial base. Summary of background data: ABC is a rare form of dystrophic pseudotumor. Less than 100 cases involving the skull have been reported in the literature, most of them localised in the cranial vault. Cranial base locations are rare and difficult to treat. We selected this treatment after a very rapid recurrence of the lesion following a partial resection. Method. - After a partial resection of a 10 cm petro-occipital ABC that encased the vertebral artery and the lower cranial nerves, an Ommaya reservoir was implanted with a catheter tip inside the ABC. Repeated intralesional injections of calcitonin were performed through the reservoir. RESULTS: Shrinkage of the cyst occurred with disappearance of its heterogeneous cystic content and ossification of its walls. There was no complication and the lesion remains quiescent at a 3 year follow-up. CONCLUSION: We reviewed the pertinent literature concerning percutaneous treatment of ABC. The percutaneous intralesionnal injection of calcitonin was reported in the literature only in 3 publications reporting 9 cases that did not involve the skull. This treatment seems safe and effective, worthy in cranial base ABCs that are difficult to resect completely.     

镍钛形状记忆合金锔钉用于硅橡胶涤纶丝网颅骨修补

为解决硅橡胶涤纶丝网颅骨修补用丝线固定手术操作繁琐、固定不牢等问题，先将镍钛形状记忆合金锔钉置于０℃～３℃水中，锔钉变软，用撑开器将其臂杆拉长３ｍｍ，锔钉的两脚与臂杆间夹角加大成直角。然后将锔钉的两脚钉入颅骨与成形片上的两个钻孔中，用热盐水纱布热敷锔钉，锔钉遇热立即恢复原状，并产生恢复力，将颅骨和成形片牢固锔在一起。１９８７年８月～１９９５年８月，临床应用这种锔钉行颅骨修补１０１例，随访到１００例，随访时间为１年～８年。结果，９８例术后无不良反应，２例额骨缺损者，术后第一天发现患侧额肌运动障碍，术后２个月恢复正常。无一例发生锔钉松动和成形片错位。认为，镍钛形状记忆合金锔钉用于硅橡胶涤纶丝网颅骨修补有以下优点：①手术操作简便；②固定牢固；③术后组织反应轻；④合并症少；⑤整形效果良好；⑥对颅脑ＣＴ及核磁共振检查无干扰；⑦锔钉用于颅骨修补未见致癌     

The Natural History of Late Diagnosed or Untreated Growing Skull Fractures: Report on two Cases

Summary  Growing skull fractures (GSF) are rare complications of head trauma. Cases after childhood are extremely rare and demonstrate complicated pathological conditions which necessitate extensive treatment. We report on two rare cases of intracranial cysts related to growing skull fractures which are secondary to trauma sustained during childhood, and have been discovered in adolescence.     

头皮缺损合并颅骨外露的皮瓣修复方法探讨

目的:探讨头皮缺损合并颅骨外露的皮瓣修复方法。方法:自2008年1月～2013年3月共收治头皮缺损合并颅骨外露30例,行局部头皮瓣、轴型头皮瓣转移结合皮片移植、上臂带蒂皮瓣修复。头皮缺损最大面积20cm×15cm,颅骨外露最大面积14cm×10cm。结果:共切取皮瓣34块、供瓣区植皮10例。皮瓣皮片均成活良好,术后随访6个月～4年,效果满意。结论:局部头皮旋转皮瓣是修复较小面积(直径小于7cm)头皮缺损优选方法,轴型头皮瓣修复较大面积(直径大于7cm)头皮缺损伴颅骨外露是有效方法,头皮缺损合并面部皮肤缺损行同侧上臂带蒂皮瓣修复也是较理想的方法。     

Microsurgical Maneuvers under Side-Viewing Endoscope in the Treatment of Skull Base Lesions

The objective of the present study is to elucidate the feasibility of surgical maneuvers under the side-viewing endoscope during skull base tumor removal. The study focused on 51 patients who underwent tumor removal with the assistance of a side-viewing endoscope. The side-viewing endoscope enabled visualization and removal of residual tumors obscured by the skull base bone, cranial nerves, and other vital structures after a microscopic procedure. If the surgical field is surrounded by the dura or skull base tissue, not only curettage of a tumor but also semisharp dissection and bipolar coagulation are shown to be feasible. In the subarachnoid space, however, the primary feasible surgical maneuver was suctioning of the tumor. The extent of skull base resection could be reduced in 25 cases and additional tumor removal became possible in 47 cases. Application of the side-viewing endoscope enabled removal of the tumor compartment, the exposure of which has conventionally required an extensive skull base resection. This technique is a promising option for the treatment of skull base tumors.     

游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损

目的:探讨吻合血管的游离肋骨-前锯肌-皮肤复合组织瓣修复大面积颅骨缺损的临床应用价值。方法:设计以胸背血管为营养血供的游离肋骨-前锯肌-皮肤复合组织瓣,用以修复大面积颅骨缺损10例。结果:10例患者,组织瓣完全成活9例,坏死1例。随访1～10年,患者术后外观满意,无感染、皮下积液等并发症发生。结论:游离肋骨-前锯肌-皮肤复合组织瓣可以很好地完成大面积颅骨缺损的修复,是一种理想的自体修复材料。     

肿胀技术下皮肤软组织扩张术治疗头皮缺损伴颅骨外露

目的:探讨皮肤软组织扩张术与肿胀技术相结合,修复头皮缺损伴颅骨外露的外科治疗效果.方法:将皮肤软组织扩张术与肿胀技术相结合,修复头皮缺损伴颅骨外露8例患者,与以往9例未采用肿胀技术的病例在术中出血、术后早期疼痛及术后血肿发生率进行比较.结果:应用该方法为8例患者修复头皮缺损伴颅骨外露,术中出血少,术后早期疼痛减轻,术后血肿发生率低.经术后3个月～2年的随诊,疗效满意.结论:肿胀技术下皮肤软组织扩张术治疗头皮缺损伴颅骨外露是一种安全可靠实用的方法,值得临床推广应用.     

Endoscopic transcranial and intracranial resection: case series and design of a perioperative management protocol

Purely endoscopic resections of transcranial/intracranial pathology represent an exciting minimally invasive option for some patients. There is an abundance of literature on surgical techniques, though very little deals with perioperative management, which is critical for good outcomes. We present a detailed case review and a perioperative management protocol with specific reference to skull base and neuroanatomy. We performed a retrospective chart review and analysis of outcomes and complications by approach and design and prospective employment of a perioperative management protocol in a major tertiary care referral hospital. We included patients undergoing endoscopic skull base approaches by the two senior surgeons from September 2005 to April 2009, selecting of transcranial/intracranial cases for detailed review. Our main outcome measures included perioperative morbidity, mortality, and complications; degree of resection; recurrence rate; and survival. Fifteen patients met study criteria. No perioperative mortality occurred. There were two major and four minor complications. Mean follow-up was 15 months; 11/13 patients with malignancies had no evidence of disease. A perioperative management protocol was designed from these data and has resulted in decreased lumbar drainage and increased fluid/electrolyte monitoring. Endoscopic transcranial/intracranial anterior skull base surgery is both safe and effective when a complete understanding of the surgery and perioperative management is achieved.     

Adult Growing Skull Fracture Mimicking a Skull Tumor

Summary  Growing skull fractures (GSF) are rare in adults. We report the case of an adult who was found to have a GSF 50 years after head trauma. This case highlights the need to consider GSFs in the differential diagnosis of adults with intradiploic skull lesions.     

Management of Minor Head Injuries: Admission Criteria, Radiological Evaluation and Treatment of Complications

Summary The clincal course of patients admitted following minor head injuries (Glasgow Coma Score [GCS] 13–15) has been studied less extensively than in severely head injured patients. Admission criteria, methods and indications for radiological evaluation are controversial. To study this further, a retrospective review of 633 patients admitted following such injuries to King Khalid University Hospital between 1986 and 1993 was undertaken. Their ages ranged from one month to 80 years (average 17 years). The mechanisms of injury were mainly falls in 339 (53.5%) cases and road traffic accidents in 234 (37%). None of the cases resulted from a non-accidental injury. Radiological evaluation was by skull radiography in 616 (97.3%) cases followed by CT scan in 131 (20.7%). These studies revealed a skull fracture in 78 (12.7%) cases. Six of these 78 patients with skull fracture required a neurosurgical procedure during the first week post injury. These represented 0.97% of the cases who had skull radiographs. A base of skull fracture was an ominous sign, since 3 of the 5 cases with such fractures required ventilation of which one resulted in the only mortality of this series, the fourth developed meningitis. Of the cases studied, 3 (0.5%) developed growing skull fractures all had the initial injury during their first year of life. Other complications were as follows: 25 (3.9%) early post-traumatic seizures, 10 (1.6%) chronic subdural haematomas, 9 (1.4%) extradural haematomas, 2 (0.3%) post-traumatic hydrocephalus and one (0.2%) cerebral abscess. We conclude that patients who have an abnormal GCS, a neurological deficit, post-traumatic seizure, signs or suspicion of basal or depressed skull fracture should be admitted for observation because of the risk of deterioration. Patients with a history of loss of consciousness or amnesia without any of the previous may be discharged to be observed at home by a competent observer, otherwise, will need admission for observation. Radiological evaluation once indicated must be by CT scan. There is no benefit from immediate skull radiography in the initial evaluation of minor head injuries. The indications for CT are an abnormal GCS, presence of neurological deficit, signs of basilar or depressed fracture and persistent or progressive headache or vomiting. Infants with minor injuries should be followed up at least once after two to three months for possible growing fractures.     

Delayed occurrence of intracranial supratentorial chondroma following compound depressed skull fracture

Summary We describe an exceptional case of a frontal convexity chondroma arising at the site of a compound depressed skull fracture operated on 12 years earlier. We conclude that intracranial chondroma should be included in the differential diagnosis of a calcified mass for the patients who had had a compound, depressed skull fracture along the suture line, especially in cases of dural laceration by the fragmented bone.     

额眶区凹陷性骨折整复术式探讨

目的 探索额眶区凹陷性骨折手术修复整形术式.方法 在额眶骨折区外周作冠状切口,翻转皮瓣后,在凹陷性骨折旁开约2 cm左右范围钻孔,形成游离骨瓣,在凹陷性骨折碎片周围形成足够的操作空间后,再取下游离的碎骨片,用骨膜剥离子撬起凹陷的眶板复位后用骨胶原位粘合,取下的游离性骨瓣及碎骨片复位后用骨胶粘合形成新的完整的骨瓣,内板不平整处可用骨蜡修复平整,尽可能将骨瓣内的碎骨片整理归位,再将游离性骨瓣还纳固定.结果 2000年1月至2004年12月我们为17例颅脑外伤额部及眶区巨大凹陷性骨折患者采用此方法进行了修复,所有病例均取得较好疗效,未见有任何并发症,痊愈后患者容貌恢复正常.结论 凹陷性骨折游离骨瓣成型手术整复法可以避免凹陷性骨折撬抬复位的并发症,整复效果好.     

Benign extracranial nerve sheath tumors of the skull base: postoperative morbidity and management

The purposes of this retrospective case series study were to examine the outcome of the operative treatment of extracranial nerve sheath tumors (NSTs) of the skull base and to learn the optimal management. The study was conducted at a university teaching hospital and a regional referral center. A total of 19 cases of benign extracranial NSTs of the skull base who presented to the otolaryngology department over a period of 10 years were studied regarding the clinical, radiological, and pathological features and the operative and postoperative management. In the majority, these tumors originated from cranial nerves; postoperative complications were frequent and depended on the nerve of origin. Postoperative nerve deficit was apparent in 10 cases, and a second operation was necessary in 8 cases. The greatest postoperative morbidity was associated with the parapharyngeal NSTs (i.e., dysphagia in 30%, dysphonia in 30%, and Horner's syndrome in 20% of cases). The conclusion from this study is that high postoperative morbidity resulting from surgery on skull base NSTs demands an integrated approach between the otolaryngologist, plastic surgeon, neurosurgeon, speech therapist, physiotherapist, dietician, and occupational therapist and a clear strategy of long-term follow-up.     

Intraosseous schwannoma of the vault of the skull

Intraosseous schwannoma is a rare benign tumor of the bone with characteristic radiological and histological features. The most common sites of this tumor are mandible, sacrum, und vertebral bodies. Two cases, one of which is the first diagnosed with MRI, of this tumor in the vault of the skull are presented.     

钛合金板置入在颅骨缺损修复中的应用

目的:探讨钛合金板置入在颅骨缺损修复中的应用。方法:对12例颅骨缺损的患者先进行三维CT检查,设计个性化的钛合金板置入以修复颅骨缺损。结果:本组患者均愈合良好,无感染、钛板外露及头皮血运障碍,避免了再次手术。结论:应用钛合金板修复颅骨缺损,具有良好的生物学力度,抗击性强,并发症少,生物相容性好等优点,可获得较好的治疗效果。     

自体颅骨超低温下保存再植的临床应用

目的进一步证实超低温下保存的自体颅骨为颅脑外伤患者去骨瓣减压术后理想的颅骨修复材料。方法186例颅脑损伤患者行支骨瓣减压术,骨瓣于术后立即保存于超低温冰箱,术后1~6个月行颅骨修复时行再植手术。结果组织学切片发现所有保存颅骨都保持存活,颅骨形态结构无明显变化,通过颅骨X光照片示再植后颅骨绝大多数呈骨性愈合。结论一定时间内颅骨在超低温下能有效保持存活,再植后大多数能形成骨性愈合。超低温下保存的自体颅骨是颅脑外伤减压术后最理想的颅骨修复材料。     

Meningiomas of the Pediatric Skull Base: A Review

Pediatric skull base meningiomas are rare and complex clinical entities. Meningioma is a relatively uncommon brain tumor in children, and only ∼ 27% involve the skull base. Some evidence suggests that these tumors are more likely to be atypical or malignant in children than adults. The absence of female preponderance in pediatric meningiomas is reflected in the skull base subpopulation. Skull base meningiomas in children are most likely to be found in the anterior or middle fossa base, or involving the orbit and optic nerve sheath. Petroclival, suprasellar/parasellar, cerebellopontine angle, cavernous sinus, and foramen magnum tumors are very rare. Meningiomas constitute a small proportion of reported cases of pediatric skull base pathology, and they are entirely absent from many case series. Initial gross total resection is consistently associated with superior outcomes. Surgical approaches to the pediatric skull base must take additional factors into consideration including relatively smaller anatomy, immature dentition, incompletely aerated sinuses and air cells, and altered configurations of structures such as the pterional bony complex. Multidisciplinary expertise is essential to optimizing treatment outcomes.