Intracranial actinomycosis in juvenile patients Case report and review of the literature

A case of actinomycotic brain infection in a juvenile patient is described. Cases of actinomycosis affecting the head and neck are rare, particularly in juvenile patients. In this case complete resolution of the infection was achieved by means of surgical treatment and prolonged antibiotic therapy. The authors emphasize the importance of a combined approach for treatment of this unusual brain infection and stress the difficulties involved in the diagnosis of this pathology. Received: 3 November 1997     

Cruciate hemiplegia: a clinical syndrome, a neuroanatomical controversy. Report of two cases and review of the literature

Basilar artery thrombosis has a very poor prognosis. A 56-year-old comatose man with acute basilar artery occlusion was successfully treated with local urokinase infusion which reopened the basilar artery and revealed a midbasilar stenotic plaque. This procedure was followed by a superficial temporal artery to superior cerebellar artery anastomosis for protection of the posterior circulation.     

Homozygous NADH-methemoglobin reductase and aspartylglucosaminidase deficiencies in a moderately retarded Sicilian child

We report on a 10-year-old boy with generalized deficiency of both NADH-methemoglobin reductase and aspartylglucosaminidase. Although the two enzymatic defects, both autosomal recessive traits, are associated with severe mental retardation, the patient was less retarded than his sister who had only aspartylglucosaminuria.     

The long-term postoperative trinitroglycerin hypotension in normal perfusion pressure breakthrough syndrome

The authors describe a case of normal perfusion pressure breakthrough syndrome, a catastrophic hemorrhage complicating surgery for cerebral arteriovenous malformations, due to chronic loss of autoregulation. Successful treatment was achieved with prolonged postoperative trinitroglycerin hypotension, associated with barbiturate-induced coma and artificial ventilation.     

Chronic subdural haematomas in patients aged under 50

The clinical findings in 31 patients with chronic subdural haematoma (CSH), aged between 20 and 50, are described. Aetiopathogenetic factors responsible for the formation of CSH match those of patients aged over 50 with CSH. A history of cranial trauma was present in 77% of the cases. In the remaining patients, a defect of haemostatic mechanisms was responsible for the subdural blood collection. On the computed tomography (CT) the haematoma generally appears as a thin subdural layer. The reliability of magnetic resonance imaging for detection of CSH makes it the most desirable investigation in such patients. Prognosis is influenced by preoperative clinical status and by the disease responsible for the formation of CSH.     

Pneumatic compression hemodynamics in total hip arthroplasty

A crossover study was performed to evaluate the effect of several pneumatic compression devices and active dorsoplantar flexion in 10 patients who underwent total hip arthroplasty. Using the Acuson 128XP/10 duplex ultrasound unit with a 5-MHz linear array probe, peak venous velocity and venous volume were assessed above and below the greater saphenous vein and common femoral vein junction. A computer generated randomization table was used to determine the order of the test conditions. The pneumatic compression devices evaluated included two foot pumps, one foot and calf pump, one calf pump, and three calf and thigh pumps. Statistical analyses included analysis of variance and analysis of variance with covariance between devices and patients. The covariates tested were the baseline measurements and the order in which the devices were tested. Differences between devices relate in part to the frequency and rate of inflation and the location and type of compression. Pulsatile calf and foot and calf pneumatic compression with a rapid inflation time produced the greatest increase in peak venous velocity, whereas compression of the calf and thigh showed the greatest increase in venous volume. Because patient and nursing compliance is essential to the success of mechanical prophylaxis for thromboembolic disease, the more simple, yet efficacious, devices that are easier to apply and less cumbersome appear to have a greater likelihood of success. In the active and alert patient, active dorsoplantar flexion should be encouraged.     

Surgical Management of Craniovertebral Junction Schwannomas: A Systematic Review

Background: Craniovertebral junction (CVJ) schwannomas are rare, with surgery and stereotactic radiosurgery (SRS) being effective yet challenging options. We systematically reviewed the literature on CVJ schwannomas. Methods: PubMed, Scopus, Web-of-Science, and Cochrane were searched following the PRISMA statement to include studies reporting CVJ schwannomas. Clinical features, management, and outcomes were analyzed. Results: We collected 353 patients from 101 included articles. Presenting symptoms were mostly neck pain (30.3%) and headache (26.3%), with most cranial neuropathies involving the XII (31.2%) and X (24.4%) nerves. Most tumors originated from C2 (30.9%) and XII (29.4%) nerves, being extracranial (45.1%) and intradural-extradural (44.2%). Erosion of C1–C2 vertebrae (37.1%), the hypoglossal canal (28.3%), and/or jugular foramen (20.1%) were noted. All tumors were operated, preferably with the retrosigmoid approach (36.5%), with the far-lateral approach (29.7%) or with the posterior approach and cervical laminectomy (26.9%), far-lateral approaches (14.2%), or suboccipital craniotomy with concurrent cervical laminectomy (14.2%). Complete tumor resection was obtained most frequently (61.5%). Adjuvant post-surgery stereotactic radiosurgery was delivered in 5.9% patients. Median follow-up was 27 months (range, 12–252). Symptom improvement was noted in 88.1% of cases, and cranial neuropathies showed improvement in 10.2%. Post-surgical complications occurred in 83 patients (23.5%), mostly dysphagia (7.4%), new cranial neuropathies (6.2%), and cerebrospinal fluid leak (5.9%). A total of 16 patients (4.5%) had tumor recurrence and 7 died (2%), with median overall survival of 2.7 months (range, 0.1–252). Conclusions: Microsurgical resection is safe and effective for CVJ schwannomas. Data on SRS efficacy and indications are still lacking, and its role deserves further evaluation.     

Bone density adjacent to press-fit acetabular components. A prospective analysis with quantitative computed tomography

BACKGROUND: The status of periprosthetic bone stock is an important concern when revision total hip arthroplasty is undertaken. Remodeling of periprosthetic femoral bone after total hip arthroplasty has been studied extensively, and the phenomenon of femoral stress-shielding has been well characterized. Finite element analysis and computer-simulated remodeling theory have predicted that retroacetabular bone-mineral density decreases after total hip arthroplasty; however, remodeling of periprosthetic pelvic bone in this setting has yet to be well defined. This study was conducted to evaluate the short-term natural history of periacetabular bone-mineral density following primary total hip arthroplasty. METHODS: Periacetabular bone-mineral density was studied prospectively in a group of twenty-six patients who underwent primary hybrid total hip arthroplasty for the treatment of advanced osteoarthritis. Density within the central part of the ilium (directly cephalad to a press-fit acetabular component) was assessed with serial quantitative computed tomography. Baseline density was measured within the first five days following the total hip arthroplasty. Ipsilateral density measurements were repeated at an average of 1.28 years postoperatively. Density values at corresponding levels of the contralateral ilium were obtained at both time-points in all patients to serve as internal controls. RESULTS: Bone-mineral density decreased significantly (p< or =0.001) between the two time-points on the side of the operation. The mean absolute magnitude of the interval density reduction (75 mg/cc) was greatest immediately adjacent to the implant (p<0.001), but it was also significantly reduced (by 35 mg/cc) at a distance of 10 mm cephalad to the implant (p = 0.001). Relative declines in mean density ranged from 33% to 20% of the baseline values. No focal bone resorption (osteolysis) was detected at the time of this short-term follow-up study. With the numbers available, no significant interval alteration in bone-mineral density was found on the untreated (internal control) side (p> or =0.07). CONCLUSIONS: We suggest that the observed decline in bone-mineral density represents a remodeling response to an altered stress pattern within the pelvis that was induced by the presence of the acetabular implant. This finding corroborates the predictions of finite element analysis and computer-simulated remodeling theory. It remains to be seen whether this trend of atrophy of retroacetabular bone stock will continue with longer follow-up or will ultimately affect the long-term stability of press-fit acetabular components.     

Is preoperative colonoscopy necessary in carcinoma of the colon and rectum?

The incidence of synchronous polyps of the colon has been shown to be 25 to 40 per cent and the incidence of synchronous carcinomas to be two to eight per cent. Because of this, many surgical groups now advocate routine preoperative colonoscopy on all patients with colon carcinoma. The possibility of spreading and implanting tumor cells with the colonoscope has prompted the authors to purposely avoid preoperative colonoscopy and then clear the colon of any missed lesions with an early postoperative colonoscopy. This study is a retrospective review of 104 patients who have undergone a partial colectomy for colon and rectal carcinoma followed by a postoperative colonoscopy between June 1982 and June 1986. The purpose is to determine the adequacy of intraoperative palpation to detect synchronous neoplasms, and to further define the role of perioperative colonoscopy. The results of 34 per cent synchronous polyps and 5.8 per cent synchronous carcinomas parallels previous studies. The six patients with synchronous carcinomas were discovered by intraoperative palpation and the operation was modified in four of the six patients. Postoperative colonoscopy revealed polyps in 20 per cent of the patients, but all of these were amenable to snare polypectomy or electrocoagulation. No carcinomas were overlooked by palpation. It is our conclusion that intraoperative palpation is adequate for detection of synchronous carcinomas and therefore the risk and expense of preoperative colonoscopy can be avoided. Early postoperative colonoscopy, however, is imperative to clear the colon of small polyps which have the potential to progress to carcinoma.     

A method of management of a circumferential villous tumor of the rectum

A case is presented in which a very large circumferential villous tumor was totally removed transanally with complete anatomic and physiologic restoration. Large circumferential tumors of the rectum present formidable technical problems. They may be malignant. When they are benign, abdominoperineal resection can be avoided. A less radical procedure that may be employed with complete resection of the tumor and without stricture formation, is described briefly.