Double concentric craniotomy for a craniocerebral penetrating nail. Case report and technical note

BACKGROUND: Craniocerebral penetrating injuries from nail-gun accidents are rare and usually are discovered immediately after the trauma. Several surgical procedures have been described to extract a foreign body that is infixed in the skull and has penetrated the surrounding structures; blind extraction, craniectomy, and craniotomy. CASE DESCRIPTION: We report the case of a 25-year-old ex-carpenter who presented with jacksonian seizure at the left limb. Plain radiography of the skull revealed the unexpected presence of a nail hammered in the right parietal bone, penetrating the underlying structures of the frontoparietal area up to a depth of 3 cm. The patient was operated on; a small craniotomy (1 x 1 cm) just around the head of the nail, and a concentric larger frontoparietal bone flap, involving the first craniotomy, were performed. The larger bone flap was elevated first, whereas the small bone flap with the nail infixed was carefully elevated along the axis of the nail, under direct vision of the nail tract. CONCLUSIONS: Double concentric craniotomy is the only technique that permits the removal of a foreign body that has penetrated both the skull and the brain, under direct vision, without transmitting any undue forces to the underlying structures. With this technique, control of bleeding can also be easily achieved.     

In uremia, plasma levels of anti-protein C and anti-protein S antibodies are associated with thrombosis

BACKGROUND: Vascular access thrombosis is an important cause of morbidity in patients with end-stage renal failure on maintenance hemodialysis (MHD). However, little is known about its risk factors. The present study was undertaken to evaluate the role of coagulation factors, fibrinolytic factors, and anti-phospholipid antibodies (aPL). In particular, we have evaluated the role of anti-protein C and anti-protein S antibodies in patients on MHD with and without thrombosis because no data are available in the literature. METHODS: The study group comprised 30 patients with thrombotic complications (TC), 40 patients matched for age, sex, and dialytic age with no thrombotic complications (NTC) and 400 controls. We have measured: anti-protein C antibodies, anti-protein S antibodies, anticardiolipin antibodies (ACA), anti-beta2-glycoprotein antibodies (beta2-GPI), and anti-prothrombin antibodies (aPT), along with prothrombin time, fibrinogen, plasminogen, protein C, protein S, anti-thrombin III, APC-resistance test, D-dimer, tissue-type plasminogen's activator, plasminogen activator inhibitor-1 (PAI-1), prothrombin fragment 1+2, factors of the intrinsic and extrinsic pathway, C-reactive protein, and homocysteine. RESULTS: There were no significant differences between groups for prothrombin time, fibrinogen, plasminogen, protein C, protein S, anti-thrombin III, activated protein C (APC) resistance, D-dimer, tPA, C-reactive protein, Factors II, X, and VII. The anti-beta2-GP1 and aPT were elevated in both TC and NTC patients, compared to the control group. Significant differences between TC and NTC groups were found for anti-protein C and anti-protein S antibodies, ACA-IgM, PAI-1, Factor VIII, prothrombin fragments 1+2, and homocysteine. CONCLUSION: The most novel finding was a significant elevation of anti-protein C antibodies and anti-protein S antibodies in the TC group (i.e., in patients on MHD with thrombosis of vascular access). It indicates that other pathogenetic mechanisms in addition to endothelial damage may cause hypercoagulability in uremia.     

The impact of labor at term on measures of neonatal outcome

OBJECTIVE: The purpose of this study was to determine risk assessments for a spectrum of neonatal outcomes with elective cesarean delivery versus a trial of labor for previous cesarean section and otherwise healthy patients who deliver at term. STUDY DESIGN: The perinatal/neonatal database of St. Joseph's Health Care, London, Ontario, Canada, was used to obtain the umbilical cord pH and base excess values, incidence of adverse neonatal outcomes, and patient demographics for all term (> or =37 weeks of gestation), singleton, liveborn, or intrapartum demise infants with no major anomalies who were delivered between January 1992 and March 2002 (n = 33,709 infants). Patient groupings (all patient, patient with previous cesarean delivery, and low-risk patient) with no labor versus labor were studied by a comparison of mean values/incidences for those neonatal outcomes that were available from the database with the use of linear and logistic regression analysis and controlling for potentially confounding variables. RESULTS: Labor was associated with a small drop in umbilical artery pH from approximately 7.27 to 7.25 and base excess from approximately -3.1 to -5.4 mmol/L, but this was generally well tolerated, with no difference in the incidence of 5-minute Apgar scores of <7 for any of the patient population groupings. Neonatal respiratory morbidity was increased generally in the group of elective cesarean delivery patients, which resulted in increased neonatal intensive care unit triage/admission even out to 7 days; some of this risk was likely to persist even with a policy of elective cesarean delivery after 39 weeks of gestation. Although we found no significant difference in the incidence of pathologic acidemia at birth with an umbilical artery pH <7.00, there was a risk for intrapartum/neonatal death that could be attributed to labor events per se that ranged from 1 of 882 for the patients with previous cesarean delivery to 1 of 3406 for the low-risk patients. CONCLUSION: For otherwise healthy patients at term, the risk of adverse neonatal outcomes is low, with the choice between elective cesarean delivery and trial of labor in general balancing the low risk of increased respiratory morbidity and thereby neonatal intensive care unit triage/admission against the extremely low risk of labor-related infant death and severe morbidity. However, this balance for the patients with previous cesarean delivery appears shifted, with less benefit from a trial of labor in terms of reduced respiratory morbidity and neonatal intensive care unit triage/admission and with increased labor-related severe morbidity/death, albeit with all of these still at a low level.     

Spinal adrenal cortical adenoma with oncocytic features: report of the first intramedullary case and review of the literature

Ectopic adrenal cortical neoplasms are extremely rare, and only a few have involved the CNS. We report the first case of an intramedullary oncocytic adrenal cortical neoplasm of the spinal cord with immunohistochemical (IMHC) confirmation. A 27-year-old man presented with progressive lower extremity weakness, spastic paraparesis, decreased reflexes, and hypoesthesia below T10. A spinal myelogram showed cauda equina blockade and obliteration of sacral nerve roots. This prompted emergent surgical intervention. A well-circumscribed, approximately 3 x 2 cm, light brown to tan, intramedullary tumor was identified at the level of the conus medullaris. Histologically, the tumor showed sheets and nests of plump, cytologically bland polygonal cells with abundant eosinophilic cytoplasm. A single mitosis, but no necrosis, was identified. By IMHC, the cells were positive for inhibin, melan-A, and synaptophysin, and negative for GFAP, EMA, cytokeratins, S-100, HMB-45, and chromogranin. Electron microscopy study performed from paraffin-embedded tissues demonstrated abundant mitochondria, and lipid vacuoles. This case confirms the occurrence of adrenal cortical neoplasms in the CNS and is the first report of an intradural, intramedullary adrenal cortical adenoma of the spinal cord, and the first to occur in a male. This tumor should be considered in the differential diagnosis of tumors of the CNS.     

Epstein-Barr Virus-associated Smooth Muscle Tumor of the Basal Ganglia in an HIV+ Child: Case Report and Review of the Literature

We describe the clinicopathologic features of an Epstein-Barr virus (EBV)-associated smooth muscle tumor arising in the basal ganglia of a 10-year-old human immunodeficiency virus (HIV)-positive child. Only a few cases of intracranial smooth muscle tumors are reported in the literature and virtually all of these have been extra-axial, involving the dura or sinuses in HIV+ adults. Our case underscores the need to include an EBV-associated smooth muscle tumor in the differential diagnosis when evaluating intracranial mass lesions in immunodeficient children.Corresponding author, e-mail: