Falciform ligament hernia: combination of key CT findings

A male patient in his early 90s with no history of abdominal surgery was referred to us for abdominal pain and vomiting. An abdominal computed tomography (CT) demonstrated dilated small bowel with a double beak sign and poorly enhanced wall, which indicated a closed-loop obstruction that leads to strangulation. A closed-loop bowel was located in front of the anterior and medial segments of the liver and to the right of the round ligament of the liver on axial images. Sagittal images revealed that the round ligament has deviated downward and 2 adjacent narrowed intestines were located at its cranial side. These CT findings suggested the hernia orifice was in the falciform ligament. Emergency surgery for highly suspected bowel ischemia revealed the falciform ligament hernia. A combination of the CT findings played a key role, including the double beak sign, the location of the closed-loop small bowel, and the downward deviation of the round ligament, although preoperative CT diagnosis of falciform ligament hernia is a diagnostic challenge

Usefulness of fast imaging employing steady-state acquisition magnetic resonance images for appropriate fenestration in a recurrent convexity arachnoid cyst

It is difficult for convexity arachnoid cysts to determine where the cyst should be fenestrated because there is no large cistern around the cyst. We successfully fenestrated a recurrent convexity arachnoid cyst during a second surgery because of the information provided by preoperative fast imaging employing steady-state acquisition (FIESTA) magnetic resonance (MR) imaging. A 19-year-old woman experienced a progressive headache and was diagnosed with an arachnoid cyst in the right temporal lobe, for which she underwent membranectomy. However, the cyst was gradually enlarging for 2 years after the first surgery and the patient’s headache recurred. FIESTA MR images revealed the membrane between the cyst and the distal sylvian fissure. This membrane was dissected and resected to connect to the cistern in the second surgery

Endoscopic hematoma evacuation following emergent burr hole surgery for acute subdural hematoma in critical conditions: Technical note

Background: Acute subdural hematoma (ASDH) is generally managed by large craniotomy with extended operating time and high relative blood loss. Recently, minimally invasive endoscopic hematoma evacuation of ASDH has been successfully demonstrated; however, non-elderly patients, moderate or massive cerebral contusion, and enlarging hematoma are generally not accepted as indications for endoscopic surgery. Clinical presentation: We report our experience with two ASDH patients with impending herniation successfully evacuated via an endoscopic surgery following emergent burr hole craniostomy. Case 1: A 70-year-old man was admitted to our hospital because of severe head trauma. Neurological examination demonstrated a fixed, dilated right pupil and a CT scan showed ASDH. The entire procedure was completed in approximately 2.5 h. He was transferred to a rehabilitation hospital. Case 2: A 51-year-old comatose woman was transferred to our hospital after a motor vehicle accident. Radiological examination revealed ASDH and severe multiple trauma. Acute traumatic coagulopathy was confirmed by laboratory tests. The entire procedure was completed in approximately 1.5 h. Almost complete evacuation of the hematoma was achieved. Conclusion: If intracranial pressure becomes sufficiently low after emergent burr hole craniostomy, endoscopic hematoma evacuation of ASDH may be a safe and effective method even in critically injured patients. Keywords: Acute subdural hematoma, Burr hole surgery, Endoscopic evacuation, Minimally invasive surgery, Intracranial pressure, Acute traumatic coagulopath