J.R. van Dellen

Experimental evaluation of collagen sponge as a dural graft

Early collagen products, when used as dural substitutes, promoted severe inflammatory responses and fell into disrepute. A more recent advance, collagen sponge, which is derived from bovine flexor tendons was used in this experimental study. Collagen sponge was surgically implanted as an onlay dural replacement graft following skull trephination and dural excision in 12 primates. Macroscopic, histological and electron-microscopical evaluations were performed at periods of 1, 3 and 9 months. This preliminary animal study indicated that collagen sponge is suitable to use as a graft since it does not induce any inflammatory response or adhesions in the absence of pia arachnoid injury. If forms an ideal scaffold for the early ingrowth of fibroblasts to effect dural repair.

The role of cerebrospinal fluid shunting in tuberculous meningitis

Abstract Twenty-three patients with severe tuberculous meningitis who underwent cerebrospinal fluid shunting within the first month of illness were reviewed nine months later. The criteria for and results of the use of cerebrospinal fluid shunts in tuberculous meningitis are reviewed.

Traumatic Brain Contusions: A Clinical Role for the Kinin Antagonist CP-0127

Summaryu2003Focal cerebral contusions can be dynamic and expansive, leading to delayed neurological deterioration. Due to the high mortality associated with such cerebral contusions, our standard practice had evolved into evacuating contusions in patients who had a deterioration in level of consciousness, lesions>30 cc and CT suggestion of raised ICP. Experimental brain edema studies have implicated kinins in causing 2° brain swelling. CP-0127 (Bradycor TM), a specific bradykinin antagonist, has been found to reduce cerebral edema in a cold lesion model in rats. In a randomized, single blind pilot study, a 7 day infusion of CP-0127 (3.0 ug/kg/min) was compared to placebo in patients with focal cerebral contusions presenting within 24–96 hours of closed head injury with an initial GCS 9–14. The ICP, GCS, and vital signs were monitored hourly. The total lesion burden (TLB) was measured on serial CT scans.u2003There were no differences in age, baseline GCS, TLB, initial ICP, or laboratory findings between the two groups (n=20). The mean (±s.d) rise in peak ICP from baseline was greater in the placebo group than with CP-0127 (21.9±4.7 vs 9.5±2.0, P=0.018). In addition, the mean reduction in GCS in the placebo group was significantly greater than in the CP-0127 group (4±1.0 vs 0.6±0.4, P=0.002). Significantly raised ICP and clinically significant neurological deterioration occurred in 7/9 patients on placebo (77%) and only in 1 patient (9%; n=11) on CP-0127, mandating surgery (P=0.005). There were no adverse drug reactions, significant changes in vital signs or variations in the laboratory values. The cerebral perfusion pressure was adequately maintained in all patients irrespective of therapy.u2003These preliminary results with CP-0127 provide supporting evidence that the kinin-kallikrein system could be involved in cerebral edema. In this study, treatment with CP-0127 appeared to alter the natural history of traumatic brain contusions by preventing the 2° brain swelling. In addition, CP-0127 obviated the need for surgery in the majority of treated patients. CP-0127 could act on the cerebral vasculature to limit dys-autoregulation and brain swelling or on the blood brain barrier to reduce cerebral edema.

Chronic extradural hematoma

Thirty-five patients with late extradural hematomas are described in whom the interval between injury and operation was at least seven days. Interpersonal violence was responsible for the initial injury in about two-thirds of the cases. There was a uniformly favorable outcome in all the cases The mode of presentation, features of the computed tomographic (CT) scans, and the possible mechanism of formation of chronic extradural hematomas are discussed.

Acute carotid-cavernous fistula with retained knife blade after transorbital stab wound

A patient who sustained an acute carotid-cavernous fistula due to a stab wound is presented. The management problems related to acute intracranial-penetrating injuries are discussed, with particular reference to vascular injury.

Praziquantel (pyrazinoisoquinolone) in active cerebral cysticercosis.

A prospective open therapeutic study on volunteers with active neurocysticercosis using pyrazinoisoquinolone (Praziquantel) has shown that it is a safe and effective drug. Objective assessment of the effect of treatment was by high resolution sequential computed tomographic scanning. Sixty-six patients received the drug. Forty-one records were available for complete analysis at the end of 1 year of follow-up. The concomitant use of steroids reduced side effects significantly. A 98% improvement was achieved.

Transient Peduncular Hallucinations Secondary to Brain Stem Compression by a Medulloblastoma

Almost all peduncular hallucinations have been described in patients with intrinsic lesions of the midbrain. An as yet unreported case of peduncular hallucinosis caused by posterior compression of the midbrain by a medulloblastoma in a 16-year-old boy is provided. The hallucinations and associated symptoms only ceased after removal of the tumor.

Persistence of a mycotic aneurysm of the intracavernous carotid artery

Mycotic aneurysms of the intracavernous portion of the carotid artery are rare, especially in children. In reported cases, treatment has been by antibiotics alone, or by some form of carotid surgery. In the present case only antibiotic therapy was used. Subsequent angiography showed spontaneous thrombosis of the internal carotid artery, but persistence of the mycotic aneurysm. The implications of these findings are discussed with regard to the management of the condition.

Rupture of bacterial intracranial aneurysms following replacement of cardiac valves

Abstract Two patients with rheumatic valvular heart disease are discussed in whom a bacterial intracranial aneurysm ruptured in relation to cardiac surgery. Cardiac surgery may predispose such aneurysms to rupture. Cerebral angiography for detecting unruptured aneurysms and surgical excision prior to valve replacement may be indicated in certain patients.

Mycotic intracavernous carotid artery aneurysm in childhood

A mycotic aneurysm of the intracavernous carotid artery which presented in an apparently classical manner during childhood, and was treated by surgery is described. The outcome was satisfactory. The literature relating to this rare condition is reviewed.