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Primary cranial plastic surgery as a measure of early rehabilitation
Thursday, IO July 1997 flammatory disease(parotitis, tonsillitis and appendicitis) in 6 cases, congenital heartdisease in 4 cases, meningoencephalitis in 4 cases. Level of consciousness: comaI-II in3 children, somnolence in8 children. In mostcasesintracranial hypertension andfocalsymptoms werefound. Thediagnosis wasconfirmed by ultrasonography in 12 cases. We usedCT beforeand aftersurgical intervention in the last 5 years. Classical craniotomy was undertaken in 24 patients (20 supratentorial, 4 infratentorial). In 8 cases puncture of the abscess was performed with drainage and washing out with antibiotics. In 2 cases ultrasound guided aspiration and an endoscopic technique was used.In the postoperative period8 patients (23%)died as a resultof variouscomplications.
IP-6-712! Medical treatment of haemophilus influenzae subdural empyema in infancy Teng-Yuan Shih. Chang-Gung MemorialHospital, Kaohsiumg, Taiwan Four infants with bacterial meningitis and subdural empyema were treated by medical treatment and surgical procedure. Sincethe use of computed tomography (eT), showing enhancement of the subdural collection, for diagnosis of subdural empyema, the importance of bacterial culturecanbe neglected. Based on data obtained from this review and from studiesprevious published in the literature, Haemophilus influenzae meningitis appears to have a low incidence of positive culture from subdural space. The patient is unlikely to benefitfrom surgical treatment. A noninvasive approach inan otherwise stablepatient seems appropriate. We thinkthat surgery is not alwaysindicated by CT enhancement, to determine the causing organism is anotherspecificindication.
IP-6-713I split Treatment of simple and complex skull defects by calvaria cranioplasty S. Asgari, H.A.Trost, D. Stolke. Department of Neurosurgery, University Hospital, Essen, Germany Introduction: Skull defects are mostlycaused by head injury. After removing a tumour like a meningioma, which invades the bone, it is customary to reject the boneflap. Usuallya reconstruction of the skull by usingmethylmethacrylate or other alloplastic material is possible. If the patient is very young, especially a child, autologous bone for cranioplasty is desired. Herefore the split calvaria method is available. A separate bone flap has to be divided in tabula intema and externa, The tabula externa then comes into its original place and tabula internafills the formerdefect. Method: From1990-1994 13 patients underwent split calvaria cranioplasty. The meanage was 19 years. Sevenpatients suffered from severehead injury with extensive skull impression. The remaining cases had miscellaneous diseases. After operation all the patients were frequently examined clinically and by X-raystudieswitha meanobservation periodof 2 years. Results: Without any peri- or postoperative complication all patients had got excellent wound-healing. The X-raystudiesdemonstrated that even extensive defects were well treated by split calvaria cranioplasty. In every case the cranioplasty showedbonyintegration. Conclusion: Especially in infantsand youngadultsthe splitcalvaria cranioplasty is an efficientmethod to treat skull defects. The autologous bone grows withinthe skull.
I P-6-7141
GrOWing skull fracture: A clinical study in 15 children
J.N. Guilburd, A. Rakier. Dept. Neurosurg. (Pediat. Div.)Rambam Medical Center, Haifa, Israel Fifteen cases of growing skull fractures (GSF) were surgically treated in our institution duringa periodof 3 years. GSF is not an entityobserved onlyduring infancy, we have treated cases in which the head trauma occurred after the age of two years. As not commonly known, seizures were rarely seen before surgical intervention. The main feature for deciding surgical intervention was enlargment of the skulldefectwith development of a leptomeningeal cyst revealed by CT. Surgery should include: enlarging of craniectomy in orderto find normal borders of dura, adhesiolysis and resection of cerebra-periosteal scar, opening of the cyst to subarachnoid space or ventricle, hermetic closing of dura (covering the dural suturewith biologicglue)and cranioplasty. Post operative complications were seen in only 2 caseswith accumulation of CSF requiring localdrainage of CSFand repeated lumbarpuncture (twice) in one case and ventriculo-peritoneal shunt in anotherpatient. Onecase required removal of the cranioplasty one and half year after the operation because of post traumatic infection after falling. No post operative seizures or neurological deterioration wereseen.
Pediatric Neurosurgery
S259
IP-6-71S! pseudomeningocele Diastatic fracture of the skull with in childhood Ajay Sharma, MaryAbraham, Medha Tatke. G.B. PantHospital, New Delhi, India Diastatic fracture of the skull associated with pseudomeningocele is a rare complication of traumain infancy. Although the syndrome of "Growing fracture ofthe skull"is a recognized clinical entity, its pathogenesis andoptimaltreatment is still debatable. The role of dural tear in the genesis of diastaticskull fracture is wellestablished, however, the contribution of associated arachnoid and local braindamage is not clear. On the basis of personal experience of 28 surgically treated children with clastauc fracture of the skull with pseudomeningocele, an attempt is madeto redefine the pathophysiology and optimalsurgical treatment. Thesechildren have a progressively increasing swelling at the fracture site at a variable interval follOWing closed head injury, mostly by a fall. Progressive neurological deficitand convulsions were other common features. All patients had serial Plain Skullfilms, C.T. and M.R./. which helped in understanding the exact pathological changes and guided the surgical approach. Surgical intervention included a uniform procedure involving a craniotomy, excision of leptomeningeal cyst and meningocerebral cicatrix with dura and cranioplasty. C.S.F. diversion procedure was undertaken in 4 patients because of altered C.S.F. dynamics. Observations on preoperative andpostoperative C.T.and M.R./. studiesneuropathology of the surgical material and the outcome of the surgicalintervention in thesechildren havehelped in the betterunderstanding of this disorder. However, the mechanism of progressive braindamage, despitesurgicalcorrection, as observed in most of the children, in M.A.1. undertaken after severalmonths, is not clear. Linearfracture and burstfractures in a infant with a scalp swellingmust be corrected earlyto preventa growing fracture.
IP-6-716I rehabilitation Primary cranial plastic surgery as a measure of early K.S.Ormantaev, G.K. Kurmanbekov. Almaty lnst. for Pediatrics, Kazakhstan The large number of children with severe skull and brain injury warrants considering them as a social group. Although surgical treatment is paramount, rehabilitation should insurefurtherrestoration of impaired function. In the period of 1976to 1995therewere246children withsevereinjuryto the skull whowere treated by primary cranialplasticsurgery. All the patients were treated within 6 hoursafter sustaining the injury. In the postoperative periodearly rehabilitation was undertaken with prolonged clinical observation. According to the severity of injury, 68% had brain concussion with localcompression by bonefragments, 14% had an epidural hematoma, 9% had a subdural hematoma, 7% had only localconcussion, and 2% had intracerebral hematoma. Follow-up ranged from 2 to 10 years and revealed full recovery in 182 patients, partial disability in 47, and severe disability requiring nursing care in 17. This demonstrates the efficacy of primary cranial surgery in the treatment of children withcranial injury.
IP-6-717I
Diagnosis and treatment of laceration of the brain and the dura
K.S.Ormantaev, G.K. Kurmanbekov. ScientificCenterfor Pediatrics and Child Surgery, 146 AI-Farabi Avenue, Almaty, Kazakhstan It is known that children up to the age of 3 years have their dura mater adherent to the cranial bone. From 1978 to 1994 we have treated 28 patients with fracture of the skull and laceration of the brain and dura. We have used pneumoencephalography for earlydiagnosis at the first day after the injury. The patientwas laid down on the side opposite to the area of injury, the head was lifted 20-30 degrees, 10-25 ml of sterile air was introduced intrathecally after withdrawal of 2 ml of CSFfor laboratory examination. Fifteento twentyminutes later, X-rays were made with horizontal ray course. On the pneumoencephalogram the presence of air in the fracture zone, subcutaneously or epidurally, reveals laceration of the brainand meninges. It is an indication for emergency operation. In 6 patients admitted on the 7th day after injury CSF accumulation was demonstrated subcutaneously in the area of the fracture. The early diagnosis and emergency surgical treatment proposed allows the prevention of growing skull fractures and the development of scarring and atrophyof the brain,and is important for optimal recovery of the injuredbrain in children.
IP·6-718I
Severe pediatric head injury. Analyzing the better outcome over a decade
LionLevi,JosephN. Guilburd, Menashe 2aaroor, Jean F.Soustiel, Moshe Feinsod. Rambam MedicalCenter, Haifa, Israel A decade ago,we seta database on traumapatients. Interimanalysis disclosed muchbetteroutcome of children with severehead injury.
IP-6-712! Medical treatment of haemophilus influenzae subdural empyema in infancy Teng-Yuan Shih. Chang-Gung MemorialHospital, Kaohsiumg, Taiwan Four infants with bacterial meningitis and subdural empyema were treated by medical treatment and surgical procedure. Sincethe use of computed tomography (eT), showing enhancement of the subdural collection, for diagnosis of subdural empyema, the importance of bacterial culturecanbe neglected. Based on data obtained from this review and from studiesprevious published in the literature, Haemophilus influenzae meningitis appears to have a low incidence of positive culture from subdural space. The patient is unlikely to benefitfrom surgical treatment. A noninvasive approach inan otherwise stablepatient seems appropriate. We thinkthat surgery is not alwaysindicated by CT enhancement, to determine the causing organism is anotherspecificindication.
IP-6-713I split Treatment of simple and complex skull defects by calvaria cranioplasty S. Asgari, H.A.Trost, D. Stolke. Department of Neurosurgery, University Hospital, Essen, Germany Introduction: Skull defects are mostlycaused by head injury. After removing a tumour like a meningioma, which invades the bone, it is customary to reject the boneflap. Usuallya reconstruction of the skull by usingmethylmethacrylate or other alloplastic material is possible. If the patient is very young, especially a child, autologous bone for cranioplasty is desired. Herefore the split calvaria method is available. A separate bone flap has to be divided in tabula intema and externa, The tabula externa then comes into its original place and tabula internafills the formerdefect. Method: From1990-1994 13 patients underwent split calvaria cranioplasty. The meanage was 19 years. Sevenpatients suffered from severehead injury with extensive skull impression. The remaining cases had miscellaneous diseases. After operation all the patients were frequently examined clinically and by X-raystudieswitha meanobservation periodof 2 years. Results: Without any peri- or postoperative complication all patients had got excellent wound-healing. The X-raystudiesdemonstrated that even extensive defects were well treated by split calvaria cranioplasty. In every case the cranioplasty showedbonyintegration. Conclusion: Especially in infantsand youngadultsthe splitcalvaria cranioplasty is an efficientmethod to treat skull defects. The autologous bone grows withinthe skull.
I P-6-7141
GrOWing skull fracture: A clinical study in 15 children
J.N. Guilburd, A. Rakier. Dept. Neurosurg. (Pediat. Div.)Rambam Medical Center, Haifa, Israel Fifteen cases of growing skull fractures (GSF) were surgically treated in our institution duringa periodof 3 years. GSF is not an entityobserved onlyduring infancy, we have treated cases in which the head trauma occurred after the age of two years. As not commonly known, seizures were rarely seen before surgical intervention. The main feature for deciding surgical intervention was enlargment of the skulldefectwith development of a leptomeningeal cyst revealed by CT. Surgery should include: enlarging of craniectomy in orderto find normal borders of dura, adhesiolysis and resection of cerebra-periosteal scar, opening of the cyst to subarachnoid space or ventricle, hermetic closing of dura (covering the dural suturewith biologicglue)and cranioplasty. Post operative complications were seen in only 2 caseswith accumulation of CSF requiring localdrainage of CSFand repeated lumbarpuncture (twice) in one case and ventriculo-peritoneal shunt in anotherpatient. Onecase required removal of the cranioplasty one and half year after the operation because of post traumatic infection after falling. No post operative seizures or neurological deterioration wereseen.
Pediatric Neurosurgery
S259
IP-6-71S! pseudomeningocele Diastatic fracture of the skull with in childhood Ajay Sharma, MaryAbraham, Medha Tatke. G.B. PantHospital, New Delhi, India Diastatic fracture of the skull associated with pseudomeningocele is a rare complication of traumain infancy. Although the syndrome of "Growing fracture ofthe skull"is a recognized clinical entity, its pathogenesis andoptimaltreatment is still debatable. The role of dural tear in the genesis of diastaticskull fracture is wellestablished, however, the contribution of associated arachnoid and local braindamage is not clear. On the basis of personal experience of 28 surgically treated children with clastauc fracture of the skull with pseudomeningocele, an attempt is madeto redefine the pathophysiology and optimalsurgical treatment. Thesechildren have a progressively increasing swelling at the fracture site at a variable interval follOWing closed head injury, mostly by a fall. Progressive neurological deficitand convulsions were other common features. All patients had serial Plain Skullfilms, C.T. and M.R./. which helped in understanding the exact pathological changes and guided the surgical approach. Surgical intervention included a uniform procedure involving a craniotomy, excision of leptomeningeal cyst and meningocerebral cicatrix with dura and cranioplasty. C.S.F. diversion procedure was undertaken in 4 patients because of altered C.S.F. dynamics. Observations on preoperative andpostoperative C.T.and M.R./. studiesneuropathology of the surgical material and the outcome of the surgicalintervention in thesechildren havehelped in the betterunderstanding of this disorder. However, the mechanism of progressive braindamage, despitesurgicalcorrection, as observed in most of the children, in M.A.1. undertaken after severalmonths, is not clear. Linearfracture and burstfractures in a infant with a scalp swellingmust be corrected earlyto preventa growing fracture.
IP-6-716I rehabilitation Primary cranial plastic surgery as a measure of early K.S.Ormantaev, G.K. Kurmanbekov. Almaty lnst. for Pediatrics, Kazakhstan The large number of children with severe skull and brain injury warrants considering them as a social group. Although surgical treatment is paramount, rehabilitation should insurefurtherrestoration of impaired function. In the period of 1976to 1995therewere246children withsevereinjuryto the skull whowere treated by primary cranialplasticsurgery. All the patients were treated within 6 hoursafter sustaining the injury. In the postoperative periodearly rehabilitation was undertaken with prolonged clinical observation. According to the severity of injury, 68% had brain concussion with localcompression by bonefragments, 14% had an epidural hematoma, 9% had a subdural hematoma, 7% had only localconcussion, and 2% had intracerebral hematoma. Follow-up ranged from 2 to 10 years and revealed full recovery in 182 patients, partial disability in 47, and severe disability requiring nursing care in 17. This demonstrates the efficacy of primary cranial surgery in the treatment of children withcranial injury.
IP-6-717I
Diagnosis and treatment of laceration of the brain and the dura
K.S.Ormantaev, G.K. Kurmanbekov. ScientificCenterfor Pediatrics and Child Surgery, 146 AI-Farabi Avenue, Almaty, Kazakhstan It is known that children up to the age of 3 years have their dura mater adherent to the cranial bone. From 1978 to 1994 we have treated 28 patients with fracture of the skull and laceration of the brain and dura. We have used pneumoencephalography for earlydiagnosis at the first day after the injury. The patientwas laid down on the side opposite to the area of injury, the head was lifted 20-30 degrees, 10-25 ml of sterile air was introduced intrathecally after withdrawal of 2 ml of CSFfor laboratory examination. Fifteento twentyminutes later, X-rays were made with horizontal ray course. On the pneumoencephalogram the presence of air in the fracture zone, subcutaneously or epidurally, reveals laceration of the brainand meninges. It is an indication for emergency operation. In 6 patients admitted on the 7th day after injury CSF accumulation was demonstrated subcutaneously in the area of the fracture. The early diagnosis and emergency surgical treatment proposed allows the prevention of growing skull fractures and the development of scarring and atrophyof the brain,and is important for optimal recovery of the injuredbrain in children.
IP·6-718I
Severe pediatric head injury. Analyzing the better outcome over a decade
LionLevi,JosephN. Guilburd, Menashe 2aaroor, Jean F.Soustiel, Moshe Feinsod. Rambam MedicalCenter, Haifa, Israel A decade ago,we seta database on traumapatients. Interimanalysis disclosed muchbetteroutcome of children with severehead injury.