Emergency surgery in a severe penetrating skull base injury by a screwdriver: case report and literature review

BACKGROUND: Very few cases of severe penetrating injuries to the skull base with a seemingly innocuous object have been described in the literature. Of the cases reported, only ten involve a penetrating screwdriver. However, the choice of therapeutic management, whether it be emergency surgical or non-surgical removal of the penetrating object as well as the selected surgical approach remain quite controversial. CASE PRESENTATION: The authors describe the case of a severe penetrating skull base injury caused by a screwdriver, following an accidental fall from a ladder. The patient was admitted in Glasgow Coma Scale (GCS) 11 with a cerebrospinal fluid (CSF) leak in the right maxillary area. The tri-dimensional computerized tomography (3-D CT) scan revealed an oblique trajectory of the screwdriver shank through the skull base. The authors opted for an emergency surgical extraction of the object. A contra-lateral pterional approach was successfully performed and a two-year follow-up showed no neurological deficits. CONCLUSION: The reported case supports the choice of emergency surgical removal of the object in penetrating skull base injuries involving the anterior skull base with neurovascular lesions. Surgical aspects of the pterional approach, and in particular the left pterional approach as well as other cranio-facial approaches in severe penetrating skull base injuries are discussed

Intraspinous postlaminectomy pseudomeningocele

Pseudomeningoceles are uncommon complications of lumbar surgery. They are encapsulated cerebrospinal fluid collections developing extradurally as a consequence of incidental dural tears. They are typically located in the paraspinal compartment and occasionally reach the subcutaneous space. We describe the case of a patient in whom a postlaminectomy pseudomeningocele developed over a 10-year period within the L5 spinous process and remained completely encircled within its bony boundaries. The surgical implications of this finding are discussed

Jugular tubercle and vertebral artery/posterior inferior cerebellar artery anatomic relationship: a 3-dimensional angiography computed tomography anthropometric study

OBJECTIVE: To evaluate structural variations of the jugular tubercles (JTs) and their relationships with the vertebral artery, the posterior inferior cerebellar artery (PICA), and the vertebrobasilar junction (VBJ)METHODS: The depth, height, and width of the JTs were measured using 30 cadaveric basicranial specimens and 50 three-dimensional angiography computed tomographic (angio-CT) scans evaluating morphological variations between the 2 sides. Angio-CT analysis evaluated the relationships of the JTs with the vertebral arteries and the PICAs The location of the VBJ with respect to the JT level in the coronal plane was evaluated.RESULTS: In the cadaveric specimens, the mean JT depth ranged from 0.9 to 3.1 cm, the mean height ranged from 0.6 to 1.5 cm, and the mean width ranged from 0.4 to 1.2 cm. According to the 3-dimensional angio-CT scans, JT measurements ranged as follows: depth, 0.7 to 2.6 cm; height, 0.6 to 1.4 cm; and width, 0.3 to 1.2 cm. The vertebral artery was in close contact with the JT on the left side in 30% of cases and on the right side in 24% of the cases. On axial scans, the PICA origin was classified as anterior to the JT in 20.5% of patients on the left side and 17.4% on the right, at the JT level in 50% of patients on the left side and 45.7% on the right, and posterior to the JT in 29.5% of patients on the left side and 36.9% on the right. On coronal scans, the PICA origin was classified as superior to the JT in 13.6% of patients on the left side and 8.7% on the right, at the JT level in 54.6% of patients on the left side and 50% on the right, and inferior to the JT in 31.8% of patients on the left side and 41.3% on the right. In the coronal plane, the VBJ was located above the tubercles in 16 patients (32%), at the JT level in 28 patients (56%), and below the tubercles in 6 patients (12%).CONCLUSION: A precise morphometric analysis of the JTs on 3-dimensional CT scans was quick and safe and showed significant variations in their size and shape. The relationship of the JT with vertebral artery and the PICA varied significantly, as well as with the VBJ location. Knowledge of these morphological variations can contribute to optimal preoperative surgical planning, minimizing retraction and reducing morbidity during extreme lateral infrajugular-transtubercular exposure surgery

Management of Complex Cerebral Aneurysms

BACKGROUND: Complex intracranial aneurysms (CIAs) are challenging pathologies to treat. Characteristics making an aneurysm complex include dimension, history of previous treatment, location, absence of collateral circulation, intraluminal thrombosis, and calcification of the wall. The goal of the therapeutic process is to exclude the malformation from the cerebral circulation and both endovascular and surgical treatments are valid procedures.METHODS: Between 1990 and 2020, 170 CIAs were treated at our institution (33 ruptured, 137 unruptured). They were 3 prepetrous segment of the internal carotid artery (ICA), 14 purely intracavernous sinus, 27 intracavernous with subarachnoid extension, 60 paraclinoid, 4 ICA bifurcation, 15 anterior communicating artery, 24 middle cerebral artery, and 23 in the posterior circulation. All the patients underwent neuroradiologic examinations and images were evaluated by the neurosurgical and interventional radiologist team. Endovascular treatment was considered as the treatment of choice. Alternative treatment was surgical clipping; revascularization procedures were performed when neither endovascular treatment nor direct clipping were possible.RESULTS: Of 170 patients, 45 underwent endovascular treatment, 77 surgical clipping, and 55 revascularization procedures. In the unruptured group, 12 patients died, 22 reported major complications, 3 had minor complications, and 101 had an uneventful postoperative course. In the ruptured group, 9 patients died, 10 had minor complications, 1 minor complication, and 13 had a complete recovery.CONCLUSIONS: Endovascular treatment should represent the treatment of choice for CIAs. Alternative treatments include direct surgical clipping and revascularization. Overall, the correct identification of the therapeutic process guarantees a good clinical outcome

Small ruminant lentiviruses in goats in southern Italy: Serological evidence, risk factors and implementation of control programs

Small ruminant lentiviruses (SRLVs) can drastically affect milk production in goat flocks and only an early detection can control and prevent their spread. Since SRLVs are responsible for persistent infections, antibody screening is the most valuable tool to identify infected animals. ELISA is recommended as the election test both for its sensitivity and for its ability to detect low antibody titers, thus identifying infected animals earlier than agar gel immunodiffusion (AGID). In the present study, an investigation was conducted to assess the SRLV seroprevalence in goat flocks in southern Italy and a transversal comparative study was carried out through the analysis of the possible risk factors influencing SRLV spread. A total of 4800 sera from 1060 flocks were analyzed and overall seroprevalences of 18,64% and 51,69% at animal and herd levels, respectively, were observed. Both the region and the herd production systems were able to affect seroprevalence, differently from the herd size, probably because the mean number of goats per herd is low and the semi-intensive management is similar regardless of the dimensional class of each herd. In particular, meat producing herds showed the higher seroprevalence, as a result of the poor sanitation and low animal monitoring in comparison to milk producing herds, where animals are managed twice daily and the relationship between dams and kids is checked to guarantee an adequate quantitative/qualitative milk yield. In the absence of vaccines or effective treatments, health preventive management and seroepidemiological investigations are the only successful approach to restrict SRLV spread as observed in countries were official/voluntary control programs are carried out