Cavernous hemangioma of the skull presenting with subdural hematoma

Journal ArticleCavernous hemangioma of the calvarium is a very rare disease, and patients usually present with headaches or a visible skull deformity. Few reports of patients presenting with intradiploic or epidural hemorrhages are found in the literature. No cases of an intradural hemorrhage from a cavernous hemangioma of the skull have been reported to date. We present the case of a 50-year-old male with a symptomatic subdural hematoma resulting from a cavernous hemangioma of the calvarium that hemorrhaged and eroded through the inner table of the skull and dura. The patient went to the operating room for evacuation of the subdural hematoma and resection of the calvarial lesion. Postoperatively, the patient had an immediate relief of his symptoms and did not have a clinical or radiological recurrence. Calvarial cavernous hemangiomas should be considered in the differential diagnosis of non-traumatic subdural hematomas. Additionally, skull lesions that present with intracranial hemorrhages must be identified and resected at the time of hematoma evacuation to prevent recurrence

Atlantoaxial transarticular screw fixation: a review of surgical indications, fusion rate, complications, and lessons learned in 191 adult patients

Journal ArticleObject. In this, the first of two articles regarding C1-2 transarticular screw fixation, the authors assessed the rate of fusion, surgery-related complications, and lessons learned after C1-2 transarticular screw fixation in an adult patient series. Methods. The authors retrospectively reviewed 191 consecutive patients (107 women and 84 men; mean age 49.7 years, range 17-90 years) in whom at least one C1-2 transarticular screw was placed. Overall 353 transarticular screws were placed for trauma (85 patients), rheumatoid arthritis (63 patients), congenital anomaly (26 patients), os odontoideum (four patients), neoplasm (eight patients), and chronic cervical instability (five patients). Among these, 67 transarticular screws were placed in 36 patients as part of an occipitocervical construct. Seventeen patients had undergone 24 posterior C1-2 fusion attempts prior to referral. The mean follow-up period was 15.2 months (range 0.1-106.3 months). Fusion was achieved in 98% of cases followed to commencement of fusion or for at least 24 months. The mean duration until fusion was 9.5 months (range 3-48 months). Complications occurred in 32 patients. Most were minor; however, five patients suffered vertebral artery (VA) injury. One bilateral VA injury resulted in patient death. The others did not result in any permanent neurological sequelae. Conclusions. Based on this series, the authors have learned important lessons that can improve outcomes and safety. These include techniques to improve screw-related patient positioning, development of optimal instrumentation, improved screw materials and design, and defining the role for stereotactic navigation. Atlantoaxial transarticular screw fixation is highly effective in achieving fusion, and the complication rate is low when performed by properly trained surgeons

False-negative magnetic resonance angiography with extracranial internal carotid artery stenosis: a report of two cases and review of the literature

ManuscriptMagnetic resonance angiography (MRA) is increasingly used as a noninvasive means to assess internal carotid artery (ICA) stenosis. When used alone, however, MRA may not be sufficiently accurate in certain settings to determine whether ICA disease meets surgical criteria. Although MRA has been recognized to overestimate the degree of stenosis, the authors present 2 cases in which it severely underestimated arterial stenosis. Two male patients, 70 and 40 years old, respectively, were admitted with crescendo transient ischemic attacks. Their MRA studies suggested nonsurgical lesions of the ICA. After the patients continued to demonstrate clinical evidence of embolic disease, digital subtraction angiography (DSA) was performed on one patient and the other received a gadolinium contrast-enhanced MRA. These tests revealed critical stenosis in each patient. Both patients were taken to the operating room for awake carotid endarterectomy with heparin anticoagulation and EEG monitoring. At surgery, both patients were found to have severely stenosed ICAs with complex plaques. MRA to determine whether ICA stenosis meets surgical criteria may not be sufficiently accurate in certain clinical settings. Additional imaging studies, such as confirmatory digital ultrasonography, MRA with gadolinium contrast, or DSA may be required to determine the extent of carotid artery stenosis accurately

Pyramidal cell types drive functionally distinct cortical activity patterns during decision-making

Understanding how cortical circuits generate complex behavior requires investigating the cell types that comprise them. Functional differences across pyramidal neuron (PyN) types have been observed within cortical areas, but it is not known whether these local differences extend throughout the cortex, nor whether additional differences emerge when larger-scale dynamics are considered. We used genetic and retrograde labeling to target pyramidal tract, intratelencephalic and corticostriatal projection neurons and measured their cortex-wide activity. Each PyN type drove unique neural dynamics, both at the local and cortex-wide scales. Cortical activity and optogenetic inactivation during an auditory decision task revealed distinct functional roles. All PyNs in parietal cortex were recruited during perception of the auditory stimulus, but, surprisingly, pyramidal tract neurons had the largest causal role. In frontal cortex, all PyNs were required for accurate choices but showed distinct choice tuning. Our results reveal that rich, cell-type-specific cortical dynamics shape perceptual decisions

Rationale and design of The Delphi Trial – I(RCT)(2): international randomized clinical trial of rheumatoid craniocervical treatment, an intervention-prognostic trial comparing 'early' surgery with conservative treatment [ISRCTN65076841]

BACKGROUND: Rheumatoid arthritis is a chronic inflammatory disease, which affects 1% of the population. Hands and feet are most commonly involved followed by the cervical spine. The spinal column consists of vertebrae stabilized by an intricate network of ligaments. Especially in the upper cervical spine, rheumatoid arthritis can cause degeneration of these ligaments, causing laxity, instability and subluxation of the vertebral bodies. Subsequent compression of the spinal cord and medulla oblongata can cause severe neurological deficits and even sudden death. Once neurological deficits occur, progression is inevitable although the rapidity of progression is highly variable. The first signs and symptoms are pain at the back of the head caused by compression of the major occipital nerve, followed by loss of strength of arms and legs. The severity of the subluxation can be observed with radiological investigations (MRI, CT) with a high sensitivity. The authors have sent a Delphi Questionnaire about the current treatment strategies of craniocervical involvement by rheumatoid arthritis to an international forum of expert rheumatologists and surgeons. The timing of surgery in patients with radiographic instability without evidence of neurological deficit is an area of considerable controversy. If signs and symptoms of myelopathy are present there is little chance of recovery to normal levels after surgery. DESIGN: In this international multicenter randomized clinical trial, early surgical atlantoaxial fixation in patients with rheumatoid arthritis and radiological abnormalities without neurological deficits will be compared with prolonged conservative treatment. The main research question is whether early surgery can prevent radiological and neurological progression. A cost-effectivity analysis will be performed. 250 patients are needed to answer the research question. DISCUSSION: Early surgery could prevent serious neurological deficits, but may have peri-operative morbidity and loss of rotation of the head and neck. The objective of this study is to identify the best timing of surgery for patients at risk for the development of neurological signs and symptoms

Progressive vertebral body osteolysis after cervical disc arthroplasty.

STUDY DESIGN: Case report. OBJECTIVE: To review the management of a patient with progressive osteolysis of the vertebral body after undergoing cervical arthroplasty for management of a refractory radiculopathy. SUMMARY OF BACKGROUND DATA: Since the Food and Drug Administration\u27s (FDA) approval of cervical arthroplasty devices in 2007, many surgeons have incorporated this technology into clinical practice. As arthroplasty becomes more widespread, complications unique to this technology are inevitable. To date, only a limited number of complications have been reported in the literature suggesting the safety of this device. To the authors\u27 knowledge, this report represents the first complication of osteolysis from a keel based arthroplasty device. METHODS: A 30-year-old man underwent an uneventful C5-C6 total disc arthroplasty with initial benefit. Progressively worsening neck pain prompted repeat imaging at 9 and 15 months, which showed a progressive osteolytic process in the vicinity of the keel of the superior alloy endplate. This necessitated exploration of the surgical site, explantation of the implant and conversion of the disc arthroplasty to an arthrodesis. RESULTS: Examination of the osteolytic area did not reveal any gross abnormalities. Testing of the device by the manufacturer did not reveal any defects. A comprehensive infectious workup was negative. The osteolytic process halted after the explantation of the device. A bony arthrodesis was achieved at 6 months and the patient remains symptom free 29 months after the initial procedure and 14 months after the revision. CONCLUSION: This report illustrates an exceptional case of a progressive osteolysis with a keel based arthroplasty device. An immune mediated osteolytic process appears to be a plausible explanation for the clinical symptoms and radiographic progression seen in this case. Given the years of use of the ProDisc-C since its FDA approval in 2007, complications with this device are rare. This represents the first reported case of osteolysis from such an implant