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A patient who presented with a subarachnoid hemorrhage was found to have a saccular aneurysm arising from the proximal basilar artery. The aneurysm was bilobed, directed anteriorly and inferiorly, and associated with a proximal fenestrated segment of the basilar artery.
New angled fenestrated clips are introduced for surgery of certain difficult aneurysms. Their usefulness was proven in two cases of fusiform vertebral artery aneurysms. The aneurysms were obliterated, new parent arteries were reconstructed, and the inclusion of adjacent vital nerves and vessels in the clips was avoided. Technical problems associated with the application of these clips are discussed.
Twenty-four different kinds of fenestrated clips are introduced for the obliteration of unusual aneurysms. The clips were used for eight aneurysms of the internal carotid artery and 10 aneurysms of the vertebral artery. All but one of the aneurysms were successfully obliterated. Recommendations are made concerning the actual use of the clips.
A new aneurysm clip has been developed specifically for internal carotid artery (ICA) aneurysms. This fenestrated clip's occluding blades deviate laterally, since the majority of ICA aneurysms protrude posterolateral to the parent artery. The clip was applied safely in seven recent patients with ICA aneurysms.
The authors report a case in which bilateral cystic temporal lobe necrosis developed after treatment of nasopharyngeal lymphoepithelioma with 7000 cGy of external beam radiation. The patient presented with an isolated memory deficit that was documented by neuropsychological testing. After fenestration and internal shunting of both cysts, there was striking resolution of the lesions and of the memory deficit.
In recent years endoscopic procedures have been used more frequently to treat loculated hydrocephalus. The trapped temporal horn, a specific type of loculation, has traditionally been treated by means of ventricular shunt placement. By opening up loculations, however, this procedure can be simplified or, in some cases, even avoided. In this report the author discusses a case of trapped temporal horn that was caused by fungal meningitis and treated using endoscopically guided fenestration of the choroidal fissure, leading to clinical and radiographic resolution of the syndrome. Using this simple procedure allows the surgeon to take advantage of normal temporal horn anatomy and landmarks, avoiding the scarred and distorted region of ventricular obstruction.
Three patients with hypertension-induced basal ganglia or thalamic hemorrhage and ventricular rupture underwent corpus callosotomy and fenestration of the septum pellucidum. A patient with a left thalamic hemorrhage underwent surgery on an emergency basis and made a complete physical recovery, although she retained mild psychomotor deficits. Another patient with a large right basal ganglia hemorrhage who also underwent surgery on an emergency basis retained a spastic left hemiparesis without evident psychomotor deficits. The third patient with a left thalamic and basal ganglia hemorrhage, who was initially awake and then lapsed into stupor days later, underwent surgery, but did not recover consciousness. Hydrocephalus was reversed and effectively controlled in all three patients without having to perform a shunt placement procedure.
OBJECT: Patients with acute subdural hematomas (ASDHs) have higher mortality and lower functional recovery rates compared with those of other head-injured patients. Early surgical decompression and active intensive care treatment represent, so far, the best way to assist these patients. Paradoxically, one of the factors contributing to poor outcomes in cases of ASDHs could be rapid surgical decompression, owing to the severe extrusion of the brain through the craniotomy defect in response to acute brain swelling. To avoid the deleterious consequences of abrupt decompression of the subdural space with disruption of brain tissue, the authors have adopted a new surgical technique for evacuation of ASDHs. This procedure consists of creating multiple fenestrations of the dura (MFD) in a meshlike fashion and removing clots through the small dural openings that are left open, avoiding the creation of a wide dural opening and the disruption of and additional damage to brain tissue. METHODS: Thirty-one patients (26 male and five female patients with a mean age of 32.5 years) harboring ASDHs were treated using this method. On admission there were 16 patients (51.5%) with Glasgow Coma Scale (GCS) scores of 3 to 5, 11 patients (35.5%) with GCS scores of 6 to 8, and four patients (12.9%) with GCS scores of 9 to 12. Postoperative computerized tomography scans of the brain revealed evacuation of more than 80% of the hematoma in 29 of 31 patients. The overall mortality rate in this group was 51.6%. CONCLUSIONS: This preliminary report of a new surgical approach for patients who have sustained ASDHs should be considered to avoid abrupt disruption of the brain and to allow the gradual and gentle release of subdural clots. This is especially important in cases in which there are severe midline shifts and a tight brain. Further clinical studies should be conducted in a more selected series to estimate the impact of this new procedure on morbidity and mortality rates.
Ophthalmological problems such as papilledema, loss of visual acuity, and oculomotor palsies are common in patients with shunt malfunctions. The authors report on three patients with shunts who presented with visual loss. In each case, the diagnosis of shunt malfunction was delayed because other classic signs and symptoms of intracranial hypertension were absent. All three patients underwent optic nerve sheath fenestration (ONSF) with resultant stabilization or improvement of visual symptoms before the shunt malfunction was recognized and treated. Consideration of these cases suggests a potential protective role of ONSF for patients with shunt malfunction.
A 65 year-old male with HCM had progressively increased pericardial effusion. He also had atrial fibrillation (af), cardiac systolic dysfunction and chronic renal failure needing hemofiltration. Pericardial fenestration was carried out to improve diastolic function. Anesthetic management with fentanyl plus low-dose propofol infusion and postoperative analgesia with epidural morphine were effective for hemodynamic stability to prevent myocardial depression and to control ventricular response to atrial fibrillation. Intraoperative trans-esophageal echocardiography (TEE) monitoring was very useful for fluid therapy, inotropic support and estimation of systolic and diastolic function.
The use of a barrier membrane, with or without osseous allograft, has been shown to establish regeneration of osseous tissue around dental implants. Following three episodes of persistent symptomatic failed apicoectomy and subsequent tooth extraction, an osseointegrated implant was placed in a wide fenestrated defect. Demineralized freeze-dried bone allograft was covered by an occlusive expanded polytetrafluorethylene membrane. The reentry procedure revealed complete bone fill that followed the texture of the augmentation material beyond the previous buccal bony envelope.
Two uncommon cases of unilateral, asymmetrical hydrocephalus secondary to membranous occlusion of foramen of monro are described. Both the cases presented with clinical features of raised intracranial pressure and their cranial computerized scans (CT) revealed asymmetrical dilatation of lateral ventricles with displacement of septum pellucidum towards the side of smaller ventricle. Neuroendoscopic fenestration of septum pellucidum and foramen of monro was tried in both the cases, which remained successful in first, while the second case required unilateral ventriculoperitoneal shunt, due to failed endoscopic negotiation of narrowed foramen of monro and intraoperative bleeding during endoscopic intervention.
Replicas of freeze-fractured endothelial cells of human choroidal capillaries show fenestrations with a central thickening, as described in thin-section studies. Between the endothelial cells there are discontinuous zonulae occludentes (i.e., maculae or fasciae occludentes), composed of ridges on face A and grooves on face B of the split-cell membrane. They are also present along the sutures of the endothelial cells of venules. Close to the intercellular suture gap junctions, probably connecting capillary endothelial cells and pericytes, are found.
Since November 1994, when the first laparoscopic nephrectomy was made in Russia, 36 laparoscopic operations have been made on the kidney. 11 were nephrectomies, 21 were fenestrations of renal cysts, 4 transabdominal laparoscopies were unsuccessful.
Transcatheter creation of a de novo fenestration of a total cavopulmonary connection baffle has not been previously reported from India. We present our experience with such a procedure in a 4-year-old child with recurrent pleural effusions in the early postoperative period.
Hepatic cysts are usually asymptomatic, most being detected incidentally during imaging. Distinction has to be made between a simple hepatic cyst from more sinister types such as a parasitic cyst and a cyst occurring as part of a neoplastic process. Intervention in a simple hepatic cyst is only indicated when they become symptomatic or when they grow at a rapid rate. Surgery is the mainstay of treatment, with laparoscopic intervention becoming more and more widely accepted. We present here the first case of laparoscopic fenestration of liver cyst performed in our hospital and also review the literature on this modality of treatment.
The success of bone grafting procedures depends largely on the management and integrity of the gingival flaps. Soft tissues aid in the protection of the bone graft, participate in the revascularization of the newly formed hard tissues, and play an important role in the esthetic outcome of the reconstructive phase. Acellular dermal matrix (ADM) is a material obtained from human skin and used in plastic and reconstructive surgery as an allograft. It acts as a bioactive substrate for cell attachment and proliferation. The outcome of the use of ADM as a dressing material to treat flap fenestrations in bone grafting surgery is presented.
BACKGROUND: Prior to the era of laparoscopic surgery, open surgical deroofing was considered to be the most appropriate therapy for uncomplicated simple hepatic cysts. Recently, there have been a number of reports of successful laparoscopic fenestration of simple hepatic cysts. Simple aspiration of these cysts is associated with a high recurrence rate. Cyst sclerosis with alcohol and, more recently, minocycline hydrochloride have been found to be effective in their management. So far there have been no trials comparing laparoscopic deroofing with sclerotherapy. A lack of consensus in their management results in considerable confusion and difficulty in deciding the optimum form of therapy. METHODS: A systematic review of articles on the subject appearing in journals in the English language was conducted using the Medline database and by cross-referencing. RESULTS AND CONCLUSIONS: Both laparoscopic deroofing and cyst sclerosis have been found to be effective in partial or complete obliteration of the cyst and in the relief of symptoms produced by the cyst. It is essential to rule out cystadenoma, malignancy, biliary communication and infection prior to treating these cysts. Alcohol/minocycline based sclerotherapy has the advantage of being associated with a lower incidence of complications. Surgery is indicated if it is difficult to rule out the above mentioned conditions, in the presence of biliary communication, in those cysts where sclerosis has been ineffective and in cases of recurrence. The choice between open and laparoscopic surgery depends on the location of the cysts within the liver parenchyma.