Managing chronic headaches in the clinic.
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Algorithms↗
Biomedical subjects
Paolo A Bolognese
Publications and source records attributed to Paolo A Bolognese.
Tailored operative technique for Chiari type I malformation using intraoperative color Doppler ultrasonography.
OBJECTIVE: We describe an operative technique for Chiari Type I malformation that uses color Doppler ultrasonography as a guide for performing patient-specific posterior fossa decompressions. The technique has been used since 1999 in more than 300 operations. METHODS: On the basis of real-time anatomic and physiological measurements, the following goals of surgery were monitored: 1) adequate decompression of the cervicomedullary junction; 2) creation of a retrocerebellar space of 8 to 10 cm(3) volume; and 3) establishment of optimal cerebrospinal fluid flow between the cranial and spinal compartments. RESULTS: The size of the craniectomy was tailored to conform to the area of cerebellar impaction as demarcated by compressed subarachnoid spaces. A laminectomy was not performed unless the cerebellar tonsils were herniated below C1. Before opening the dura, color Doppler ultrasonography imaging was invaluable in planning operative strategies. A simple duraplasty without additional steps was found to be appropriate treatment in occasional patients with minimal tonsillar herniation (5-8 mm). In all other cases, it was necessary to perform an internal decompression that included lysis of the arachnoid and shrinkage of the cerebellar tonsils to achieve the goals of surgery. Optimal cerebrospinal fluid flow through the foramen magnum in anesthetized, prone patients was found to have the following characteristics: a peak velocity of 3 to 5 cm/s, bidirectional movement, and a waveform exhibiting vascular and respiratory variations. The attainment of surgical goals was confirmed in most patients by postoperative neuroimaging. CONCLUSION: Color Doppler ultrasonography imaging is an important technological advance that permits the neurosurgeon to tailor the steps of Chiari surgery according to patient-specific variables. The success of this technique depends on the mastery of a new and sophisticated monitoring modality.
Adult↗
Acute syringomyelia: case report.
OBJECTIVE AND IMPORTANCE: Syringomyelia is generally regarded as a chronic, slowly progressive disorder. We describe a case of acute dilation of the central canal of the spinal cord that presented with rapidly progressive segmental signs. CLINICAL PRESENTATION: A 29-year-old female patient who had previously undergone surgical treatment for a Chiari I malformation, syringomyelia, and hydrocephalus presented with an 8-day history of headaches, progressive paraparesis, and urinary retention. Magnetic resonance imaging scans demonstrated panventricular hydrocephalus in association with a holocord syrinx that extended to the obex. Magnetic resonance imaging scans that had been coincidentally obtained just 3 days before the onset of symptoms had revealed no evidence of hydrocephalus or syringomyelia. INTERVENTION: The patient underwent emergency revision of a failed ventriculoperitoneal shunt. Postoperatively, there was prompt resolution of the syringomyelia, hydrocephalus, and associated neurological deficits. CONCLUSION: Among patients with communicating syringomyelia, the central canal of the spinal cord participates as a "fifth ventricle" and can undergo rapid dilation in association with acute hydrocephalus. Appropriate treatment in such cases involves placement of a ventriculoperitoneal shunt.
Acute Disease↗