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Intracranial hypertension can cause secondary damage after a traumatic brain injury. Aggressive medical management might not be sufficient to alleviate the increasing intracranial pressure (ICP), and decompressive craniectomy (DC) can be considered. Decompressive craniectomy can be divided into categories, according to the timing and rationale for performing the procedure: primary (done at the time of mass lesion evacuation) and secondary craniectomy (done to treat refractory ICP). Most studies analyze primary and secondary DC together. Our hypothesis is that these two groups are distinct and the aim of this retrospective study is to evaluate the differences in order to better predict outcome after DC.
Seventy patients had DC over a period of four years at our center. They were divided into two groups based on the timing of the DC. Primary DC (44 patients) was done within 24 hours of the injury for mass lesion evacuation. Secondary DC (26 patients) was done after 24 hours and purely for the treatment of refractory ICP. Pre-op characteristics and post-op outcomes were compared between the two groups.
There was a significant difference in the mechanism of injury, the pupil abnormalities and Marshall grade between primary and secondary DC. There was also a significant difference in outcome with primary DC showing 45.5% good outcome and 40.9% mortality and secondary DC showing 73.1% good outcome and 15.4% mortality.
Primary and secondary DC have different indications and patients characteristics. Outcome prediction following DC should be adjusted according to the surgical indication.
Scedosporial infections are usually encountered in the immunocompromised patients. However, they are now emerging in the immunocompetent population and have an affinity for the central nervous system. They represent a therapeutic challenge, since they are highly resistant to most antifungal medications.
We report the case of an immunocompetent patient with multiple cerebral abscesses secondary to Scedosporium apiospermum following extracorporeal membrane oxygenation (ECMO) and review the literature about this challenging cerebral infection.
A previously healthy 33-year-old male admitted to the hospital for a community-acquired pneumonia requiring ECMO subsequently developed multiple cerebral abscesses. He was empirically treated with caspofungin, which was changed to voriconazole once surgical aspiration revealed Scedosporium apiospermum. Despite multiple aspirations, decompressive craniectomy to alleviate intracranial pressure, and an appropriate antifungal agent, the patient did not survive this aggressive infection.
Brain abscesses with Scedosporium apiospermum present a therapeutic challenge. High clinical suspicion leading to early appropriate antifungal therapy and combined surgical interventions might improve the prognosis.
Superficial anastomotic veins (SAVs) have been studied extensively but little attention has been paid to clinical studies. The aim of this study is to provide variations in the drainage patterns of SAVs depending on the intraoperative findings.
A total of 251 craniotomies due to intractable temporal lobe epilepsy were performed between 1972 and 1987 at the Montreal Neurological Institute. The courses of the three largest SAVs including the vein of Trolard (VT), vein of Labbe (VL) and superficial Sylvian vein (SSV) were studied.
All three veins showed variable courses. The most common predominant vein was the combination of the VL + SSV. The VT and VL were frequently coursed at the level of the central vein and middle temporal vein, respectively. On the right hemisphere the SSV was the predominant type while the VL tended to be predominant on the left hemisphere. A combination of VL and SSV was predominant in patients with right and/or left hemispheric dominance.
The SAVs showed considerable variation in their courses and it is difficult to define an exact pattern although some courses showed constant directions. Attention should be paid not to damage these veins since in a considerable number of cases a single dominant vein may be responsible for draining a majority of the lateral surface of cerebral hemisphere.
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