The role of strict patient-positioning during nursing in the management of intracerebral migration of gravitational bullet injury

The intracranial migration of bullet was described in literature since Cushing time and the First World War [1]. The literature is still away from delivering a clear guideline and constitutes more of case reports rather than comprehensive well-designed studies [2-13], this mostly due to the variability and diversity in the presentation and management of such cases. The migration of bullet can be a sequel of any type of penetrating injury to the skull [14]. Intracranial migration after gravitational (falling) bullet injury is a unique type of injury that constitutes of significant human and material losses with differences in biomechanics and structural brain changes after the insult especially regarding the velocity of impact and the degree of yaw for the intracranially settled bullet [15]. The gravitational bullets injuries are considered by the international disease classification system as celebratory firing, that is quite common and is part of the traditional happy (marriage) or funeral event in the middle east in general and in rural areas of Iraq in particular, and also reported in some areas around the world (South America, North Africa, and middle of Asia) [15,16]

Cranio-cervical bone hyperpneumatization: An overview and illustrative case

The pneumatization of regions such as the apex of the temporal crag, the mastoid cells and the perilaberytic region is considered physiological in adults. The process of craniocervical pneumatization in unhealthy adults derives from a dysfunction at the level of the eustachian tube, which provides a valve effect causing an increase in pressure at the level of the middle ear, forcing the entry of air into the dome of the skull through the opening of the occipitomastoidal suture. The process of standard pneumatization of the temporal bones, begins in the final weeks preceding birth, characterized by a decrease in the embryonic mesenchyme at the antrum level and progresses through childhood until adolescence, when the stone portion at the level of the rock is pneumatized; Normal variants have been reported, such as pneumatization that extends from the temporal scale to behind the sigmoid sinus. With regard to the process of hyperneumatization, several etiologies have been proposed that a congenital process versus an acquired process to develop this condition should be compared. The present illustrative case is a seventy-three years old male presented to the outpatient clinic with chronic recurrent occipital headache, already investigated by general practitioner for elevated blood pressure which was excluded. We had checked him to exclude the cervical spinal origin of the occipital headache which was then excluded too. This case scenario demonstrates the debate about how to deal with such cases and thus the review will bring the attention of those who take care of such radiological findings to keep in mind the possible causes and complications according to the reported cases till now. We concluded that the hyperpneumatization of the craniocervical junction is an uncommon radiological finding that is usually asymptomatic although it can entail serious complications in some instances, especially when it enlarges progressively, which may be due to an acquired process. Thus, craniocervical hyperpneumatization deserves highlighting for the managing team to gain fluent treatment and better patient outcome

Endoscopic third ventriculostomy: Complications and avoidance

Introduction. Endoscopic third ventriculostomy (ETV) is the treatment of choice in obstructive hydrocephalus. It has become the main standard choice in management since 1962. However, there is scant data regarding the complications from clinical or multi-centre trials. This study highlights the specific complications and prevention methods related to ETV in Neurosurgical Teaching Hospital, Baghdad, Iraq. Methods. It is a prospective case series study conducted on cases in the Neurosurgical Teaching Hospital in Baghdad, Iraq, from January 2014- October 2019. We selected ninety patients. The sample selection was convenient as any patients admitted in the study period who met the selection criteria were included. All included patients underwent a Computerized Tomography scan or Magnetic Resonance Imaging in the periprocedural management. Results. Ninety cases have 59 (65.5%) females and 31 (34.5%) males. The most common cause of hydrocephalus is congenital causes (51 cases (56.6%), especially within the first decade of life. Aqueduct stenosis is the leading cause in 37 cases (72%). ETV complications were found in 32 cases (35.5%). The most common cause of complications is congenital cases of 14 (15%). Intraoperative complications include bleeding (mild, moderate, and severe) in 18 cases (20%). Mild bleeding constitutes 15 cases (16.6%) of all complicated cases. Conclusion. ETV is a standard procedure in the management of obstructive hydrocephalus. The complication rate is found in around one-third of the cases in our study. Surgeons’ selection of indicated patients and better surgical experience decrease the failure rate of ETV and complications

Management of brain aneurysm neck-avulsion during clipping surgery: Illustrative case and literature review

Background. Intra-operative rupture (IOR) of intracranial aneurysms is a critical event affecting the operation course and the patient’s outcome. However, A rupture induced by an avulsion in the aneurysmal neck is exceedingly challenging, as sealing the neck tear by clip application might result in ischemic injury due to parent vessel occlusion. Here we reviewed the literature regarding the intraoperative avulsion of the aneurysmal neck with an illustrative case to provide explanations of its surgical management intricacies. Methods. A Midline PubMed literature review was performed using the following keywords; (Aneurysm) AND (neck) AND (surgery or clipping) AND (tear OR avulsion). Fifty-three results were found initially. After excluding non-human subject studies, and non-English studies, two independent researchers examined the title and the abstract for the cases of neck tear or avulsion with its management. Results. Fourteen articles were found to be included in this study. The average age of the cases is around 57 years. The percentages of females in the review were 62% (8/13), and among the males, 38% (5/13). Regarding the locations, PcomA and AcomA were both 23% (3/13) of the cases; other locations include ACA, 15%, and MCA, 15%. The surgical techniques that opted from the literature include the cotton clip method, clip wrapping, parallel clipping and micro-suturing Conclusion. IOR due to aneurysmal neck avulsion is a devastating surgical complication, and its management may differ according to the extent of the rupture. Choosing the most convenient technique depends on the surgeon’s knowledge and experience

Management of brain aneurysm neck-avulsion during clipping surgery

Background. Intra-operative rupture (IOR) of intracranial aneurysms is a critical event affecting the operation course and the patient’s outcome. However, A rupture induced by an avulsion in the aneurysmal neck is exceedingly challenging, as sealing the neck tear by clip application might result in ischemic injury due to parent vessel occlusion. Here we reviewed the literature regarding the intraoperative avulsion of the aneurysmal neck with an illustrative case to provide explanations of its surgical management intricacies. Methods. A Midline PubMed literature review was performed using the following keywords; (Aneurysm) AND (neck) AND (surgery or clipping) AND (tear OR avulsion). Fifty-three results were found initially. After excluding non-human subject studies, and non-English studies, two independent researchers examined the title and the abstract for the cases of neck tear or avulsion with its management. Results. Fourteen articles were found to be included in this study. The average age of the cases is around 57 years. The percentages of females in the review were 62% (8/13), and among the males, 38% (5/13). Regarding the locations, PcomA and AcomA were both 23% (3/13) of the cases; other locations include ACA, 15%, and MCA, 15%. The surgical techniques that opted from the literature include the cotton clip method, clip wrapping, parallel clipping and micro-suturing Conclusion. IOR due to aneurysmal neck avulsion is a devastating surgical complication, and its management may differ according to the extent of the rupture. Choosing the most convenient technique depends on the surgeon’s knowledge and experience

Mobilization of the temporal pole as integrated step in microsurgical clipping of pure posteriorly directed posterior communicating artery aneurysm

A pure posteriorly posterior communicating artery (PCoA) aneurysm represents a surgical challenge. This is mainly when there is a need for good exposure of the aneurysmal neck, sac, PCoA, and anterior choroidal arteries. Ruptured pure posteriorly directed PCoA aneurysm imposes significantly extra challenge as the surgeon undergoes dissection through a tight brain. Even with measures commonly used to attain brain relaxation like the lumbar drain and cisternal fenestration. Here, we describe a technique for posterior temporal pole mobilization (TPM) as an integrated part of microsurgical clipping of ruptured pure posteriorly directed PCoA aneurysms. This technique is implicated in twenty-three successive cases of ruptured PCoA aneurysms in the neurosurgery teaching hospital in Baghdad, Iraq, with no reported complications