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PubMed1998

["Paradoxical" herniation after decompressive trephining].

The intracranial space is divided into two large compartments by the tentorium. The hydrostatic pressure of spinal fluid is responsible for buoyancy of the brain within these compartments. In patients with craniectomy this equilibrium is exposed to atmospheric pressure. We report on four cases of reversible herniation after either bilateral or unilateral decompressive craniectomy performed for increased intracranial pressure (ICP) and failure of conservative ICP treatment. All four patients had survived a severe neurological disease (encephalitis, subdural haematoma, stroke) which required craniectomy to control raised ICP. All were successfully weaned from the ventilator and awake and CT scans showed no space-occupying lesion anymore. The patients showed a typical "sunken pattern" at the trepanation site. All patients developed clinical signs of transtentorial herniation (i.e. unilateral dilated pupils, deteriorated alertness, and extensor posturing) shortly after either diagnostic or presumed therapeutic lumbar puncture. One patient developed herniation a second time while in the typical 30 degrees upright position. After craniectomy, transtentorial herniation is possible even in the absence of increased ICP. It is related to a negative gradient between atmospheric and intracranial pressure, which is enhanced by changes in the CSF compartment following lumbar puncture. Lumbar puncture should be avoided if possible and, when necessary, only be performed in the head-down position. Acute therapy in these cases is quite simple; it requires flat or even head-down positioning and early cranioplasty.

Adult↗
PubMed2001

[Combined cataract-glaucoma surgery with deep sclerectomy. An alternative to gonio-trephination in the intra- and early postoperative phases].

BACKGROUND: We examined the value of deep sclerectomy combined with phacoemulsification as a surgical technique in the peri- and postoperative phases. MATERIALS AND METHODS: Deep sclerectomy with phacoemulsification was carried out in 18 patients. Mean postoperative follow-up was 7.5 weeks. RESULTS: Deep sclerectomy was more difficult to perform than goniotrephination. We observed neither fibrin reaction nor hypotonic dysregulation (intraocular pressure, IOP, < 8 mmHg). Five patients required additional pressure-lowering drugs during postoperative IOP regulation. CONCLUSION: We consider the low inflammatory response in the early postoperative phase to outweigh the greater surgical difficulty and prolonged surgery time. Further studies must verify whether higher IOP during the early postoperative phase is sufficient for good long-term IOP regulation.

Anterior Chamber↗
PubMed1996

Time-related deviations of fibronectin and type I, II and III collagen on the interface between a hydroxyapatite disc and the rim of a calvarial trephine defect in rabbits.

To pursue the events around hydroxyapatite (HA) discs (diameter 9 mm), implanted in calvarial defects in rabbits (diameter 11 mm), immunohistochemical changes of fibronectin and type I, II and III collagen were quantitatively determined in the connective tissue-HA (CTHA) and host bone-HA (BHA) interface at 8, 12 and 16 wk postimplantation. A marked enhancement of type I collagen staining in the BHA interface was noted at the 12th and the 16th wk in comparison to the CTHA interface and connective tissue in the untreated control defect. However, one of the characteristics of the staining in the CTHA interface was the finding of exceptionally high fibronectin and type III collagen at the 8th and the 12th wk in contrast to the BHA interface and the untreated control defect. The change in these immunohistochemically determined compositions was probably due to an active proliferation of vascular components in the CTHA interface. Bone regeneration in the CTHA interface was parallel to an increase in type I collagen and a decrease in fibronectin and type III collagen from 8 to 16 wk. This study indicated that variances in composition or characteristics of connective tissue in CTHA interface have taken place ahead of bone morphogenesis. The time-related derivation of connective tissue matrix components in the BHA and CTHA interface was confined to the interaction of implanted HA with host tissues in contact with the implant.

Animals↗