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PubMedDate not supplied

[The diagnosis and surgical treatment of traumatic hematomas of the posterior cranial fossa].

The symptomatology and results of treatment of 26 patients with traumatic hematomas of the posterior cranial fossa (PCF) are analysed. The hematomas were verified on operation in 19 patients and on postmortem examination in the other patients. It is concluded that the diagnosis of PCF hematomas is based on a combination of signs: cervico-occipital mechanism of the trauma, fracture of the occipital bone, cerebello-stem symptomatology, and acute hydrocephalus. The formation of trephination openings on the line of the fracture of the occipital bone is considered expedient in the presence of the above listed signs of affection of the PCF structures and the absence of computer tomography. Tests for induced stem potentials must also be included in the diagnostic complex. Total lethality was 53.8%, surgical lethality--25%.

Adult↗
PubMedDate not supplied

[Reduction of the mortality from acute subdural hematoma. Comparison of 2 series (1979-1982 and 1987-1989) of patients operated on at the Hospital de la Vall d'Hebron].

Several clinical variables from a series of 101 patients with acute subdural hematoma (ASDH) operated on during the period 1979-1989 were compared with those from another group of 43 patients who were operated on during the period 1987-1989. Twenty-seven patients (26.7%) in the earlier period and 15 (34.8%) in the later one were younger than 40 years. The difference was not significant. There was a higher proportion of patients, 41 (40.5%), in the earlier period (1979-1982) who had traffic accidents than in the 1987-1989 period, where trauma was the mechanism in 15 patients (38.8%). However, the difference was not significant. Seven patients (6.9%) from the earlier group and 18 (41.9%) from the later group had a lucid interval. This difference was significant (p less than 0.001). During the 1979-1982 period 80 patients (79.2%) were comatose on admission as compared with 27 (62.7%) during 1987-1989. The difference was significant (p less than 0.05). A small group of 11 patients (10.8%) from the earlier series were operated on by means of craniotomy or trephine; by contrast, this approach was used in 35 (81.3%) patients from the later series. The difference was significant (p less than 0.001). Seventy-nine (78.2%) and 26 (60.4%) patients died in the periods 1979-1982 and 1987-1989, respectively. The difference between the mortality rates of both groups were significant (p less than 0.05). Our data suggest that the earlier diagnosis and the use of wider surgical procedures have contributed to the reduction in mortality.

Accidents, Traffic↗
PubMed1990

Study of long-term survival after transsphenoidal hypophysectomy in clinically normal dogs.

Experimental hypophysectomies were performed in 7 clinically normal dogs, using a new modification of the transsphenoidal approach. This approach facilitated centering of the sphenoid bone trephination and allowed safe exposure of the hypophysis regardless of the size or shape of a dog's skull. Complications did not occur during surgery and all dogs recovered well from surgery. Growth hormone secretory capacity was measured over a 3-month period to assess completeness of hypophysectomies. One dog was euthanatized 2 months after surgery, 4 dogs were euthanatized at 3 months after surgery, and 2 dogs were allowed to survive and their progress was followed for 2.5 years. Soft palate dehiscence and keratoconjunctivitis sicca developed in 2 of the dogs. The technical deficiencies responsible for these complications were corrected shortly after the beginning of the study. In 4 of the 5 necropsied dogs, minute remnants of adenohypophyseal tissue were found in the sellae turcica. Measurement of in vivo growth hormone secretory capacity revealed that these remnants had an altered stage of functional activity. Although complete hypophysectomy was not achieved consistently, the main technical obstacle of hypophysectomy, the reliable identification and the avoidance of the vascular structures surrounding the hypophysis, has seemingly been overcome. The surgical technique proved to enhance the safety of hypophysectomy, and the procedure can be recommended to treat clinical cases of canine pituitary-dependent hyperadrenocorticism. The clinical significance of potential subtotal hypophysectomy remains yet to be evaluated.

Animals↗
PubMed1987

[Treatment of acute subdural hematoma with low GCS score].

In order to clarify the present problems in the treatment of acute subdural hematoma with low GCS score (5 or less), we studied the difference of the outcomes from two different surgical treatments for these patients. The present series included 30 patients who had GCS scores of 3, 4 or 5, and they were divided into two groups: 16 in DH group who had decompressive hemicraniectomy and 14 in HITT group who had hematoma irrigation with trephination therapy. The mean age of the patients was 47 years. They all had an intensive medical management including barbiturate therapy under intracranial pressure (ICP) monitoring after the operation. Time course of ICP after operation was classified as controlled, high but reduced and uncontrollable, based on the ICP level of 30 mmHg. The outcomes of the patients were determined by use of Glasgow outcome scale and classified into good, poor and dead. In these patients, the outcome was good in 13.3%, poor in 23.3% and dead in 63.4%. There was no survived case in those with GCS score of 3. The mortality rate in older patients over 60 years was high as 81.8%. ICP was well controlled in 2 patients (12.4%) in DH group. But there is no such case in HITT group. Uncontrollable ICP was more frequently seen in HITT group than in DH group. The patients showed different outcomes in the two types of treatment. Good outcome was found in 18.7% and the mortality rate was 56.3% in DH group. On the other hand, only one patient (7.1%) showed good outcome and the mortality rate of 71.4% in HITT group.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1979

Emergency evaluation of head injuries in the elderly.

The first hour after head injury in the elderly is the most critical. Airway obstruction and impaired cardiovascular reflex mechanisms are the major initial problems. A patient with an extracerebral hematoma may need emergency trephination. You must look for the specific clinical indications or use a CAT scan to identify surgically accessible lesions.

Aged↗
PubMedDate not supplied

[Surgical tactics in injuries and compression of the superior sagittal sinus].

It is shown from the analysis of 38 cases with injury to and compression of the sagittal sinus that these traumas are often attended by contusion of the brain in the sagittal-parasagittal area and are characterized by hemiparesis with predominance of motor disorders in the distal parts of the limbs, often with ischuria. They are managed surgically. Emergency surgery is indicated in hemorrhage and when there is a clinical picture of progressive compression of the brain. In the other cases trephination of the skull should be postponed until shock is completely relieved and wound infection cured and should be performed by a skilled neurosurgeon and anesthetist when a sufficient amount of stored blood is available. Compression of the sagittal sinus for a period of up to 6 weeks did not cause any clinically marked disorders of cerebral circulation.

Adolescent↗
PubMed1994

Removal of inspissated purulent exudate from the ventral conchal sinus of three standing horses.

Primary paranasal sinusitis, complicated by inspissated purulent exudate in a ventral conchal sinus, was diagnosed in 3 horses. Partial nasal obstruction, caused by axial deviation of the ventral concha, was detected endoscopically in 2 of the horses. A mass, dorsal to the maxillary molars, was detected via a lateral radiographic view of the skull of 3 horses and on the dorsoventral view of 1 of the horses. Inspissated purulent exudate was removed from the ventral conchal sinus of the horses via trephination of the conchofrontal sinus and penetration of the caudal wall of the ventral conchal sinus. The procedure was performed with the horses standing and sedated.

Animals↗
PubMed1975

Full-thickness eye wall biopsy. II. In primates.

We devised a technique to perform an intact full-thickness eye wall biopsy in primates. An eye basket is sutured to the eye wall for stabilization. Trephines demarcate and incise a 4 to 7 mm. circumferential area of sclera; diathermy deepens the incision until perforation is achieved. The biopsy specimen is removed and immediately fixed for histologic evaluation, and the eye wall defect is covered by a 7 mm. scleral homograft. Our results showed that histologically excellent biopsies can be obtained with minimal damage to the eye.

Animals↗
PubMed1993

New bone and connective tissue ingrowth in a hydroxyapatite block repairing a rabbit skull defect.

Standardized 11 mm rabbit skull trephine defects were implanted with 9 mm diameter hydroxyapatite (HA) blocks. New bone and connective tissue ingrowth was studied histologically and by X-ray after 8, 12 and 16 weeks. Empty defects without HA served as controls. Increasing amounts of new bone and fibrous connective tissue appeared inside the pores of the HA block with time. The interface area was constituted at 8 weeks predominantly by fibrous connective tissue which changed gradually at 12 weeks and definitely showed a solid bony union between the HA block and the host bone at 16 weeks. Movement of the implant was a possible reason for the prolonged healing time. However, trabecular new bone ingrowth appeared slowly even though a contact between the host bone and the HA block was not primarily provided. Comparison between a calvarial defect inserted with an HA block and an empty defect is not critically valuable, although the amount of new bone increased and that of connective tissue decreased in the empty defect during 16 weeks of observation. At the end of the experiment the HA-filled defect was seen to be totally repaired while the empty control defect was repaired with new bone to about half of its area.

Animals↗
PubMed1996

The role of midazolam-induced sedation in bone marrow aspiration/trephine biopsies.

This study was undertaken in 102 adult patients to evaluate the safety and efficacy of intravenous (i.v.) midazolam in the setting of bone marrow aspiration and trephine biopsy (BMAT). Combined local anaesthetic (LA) and sedation was used in 87% of patients and 13% received LA alone. Amnesia occurred in all sedated patients with only 9% experiencing a mild degree of post-procedure pain. This contrasted sharply with the non-sedated group, in whom 85% had intense pain during the biopsy followed by protracted local discomfort in approximately 54%. Drowsiness and some psychomotor impairment were the only notable sedation-related side-effects in approximately 20%. None required assisted ventilation. There was a resounding patient preference for BMAT with sedation. Considering the ease of use, safety and efficacy of i.v. midazolam, the availability of flumazenil as a reversal agent and the undoubted positive effects on quality of life, we would advocate using it in BMAT provided that there were no contraindications.

Adolescent↗
PubMed1997

Ancient myth, modern reality: a brief history of transplantation.

From trephination to modern surgical procedures, transplantation is an exciting technology that has evolved over centuries. This article reviews the historical incidences of organ and tissue transplantation among humans and reflects on accomplishments made in general surgery that assisted transplant technology. Following a brief historical overview, the article focuses on modern transplanting issues including: development of immunosuppressive therapy, organ availability, qualifications for donors and recipients, organ procurement, and new transplant technology.

Brain Death↗
PubMed1998

Comparison of topical administration of clotrimazole through surgically placed versus nonsurgically placed catheters for treatment of nasal aspergillosis in dogs: 60 cases (1990-1996).

OBJECTIVE: To examine the clinical response to topical administration of clotrimazole in dogs with nasal aspergillosis, to compare effect of surgically placed versus nonsurgically placed catheters used for administration on outcome, and to examine whether subjective scoring of computed tomographic images can predict outcome. DESIGN: Retrospective case series. ANIMALS: 60 dogs with nasal aspergillosis. PROCEDURE: Information including signalment, history, diagnostics, treatment method, and outcome was retrieved from medical records of dogs with nasal aspergillosis treated between 1990 and 1996 at the University of California School of Veterinary Medicine or cooperating referral practices. Final outcome was determined by telephone conversations with owners and referring veterinarians. Images obtained before treatment were subjectively assessed to develop an algorithm for predicting outcome. RESULTS: Clotrimazole solution (1%) was infused during a 1-hour period via catheters surgically placed in the frontal sinus and nose (27 dogs) and via nonsurgically placed catheters in the nose (18). An additional 15 dogs received 2 to 4 infusions by either route. Topical administration of clotrimazole resulted in resolution of clinical disease in 65% of dogs after 1 treatment and 87% of dogs after one or more treatments. The scoring system correctly classified dogs with unfavorable and favorable responses 71 to 78% and 79 to 93% of the time, respectively. CLINICAL IMPLICATIONS: Topical administration of clotrimazole, using either technique, was an effective treatment for nasal aspergillosis in dogs. Use of non-invasive intranasal infusion of clotrimazole eliminated the need for surgical trephination of frontal sinuses in many dogs and was associated with fewer complications.

Administration, Intranasal↗
PubMed1998

Laser energy reaching the posterior pole during transscleral cyclophotocoagulation.

OBJECTIVE: To measure scattered laser energy reaching the posterior pole during transscleral cyclophotocoagulation. METHODS: Transscleral cyclophotocoagulation was performed on 4 cadaver eyes with Nd:YAG noncontact, Nd:YAG contact, and diode contact lasers. Energy was measured with a photodiode through a 7-mm trephined hole in the posterior pole. Average percentage power, average power, and average energy transmission were calculated. American Conference of Governmental Industrial Hygienists (ACGIH) guidelines were used to calculate allowable energy exposures for each laser. RESULTS: All 3 lasers transmitted 3% to 5% of the power to the posterior pole. The average energy transmission was 240 to 260 mJ for all lasers. The contact lasers had an average power transmission of 120 mW. The noncontact Nd:YAG laser, with shorter pulse duration, had an average power transmission of 13,000 mW, significantly greater than that of the other lasers. The ACGIH guidelines for allowable energy exposures were 93 mJ for the noncontact Nd:YAG laser, 1300 mJ for the contact Nd:YAG laser, and 440 mJ for the contact diode laser. CONCLUSIONS: Three percent to 5% of laser power delivered during cyclophotocoagulation reaches the posterior pole. Exposure energies may approach or exceed ACGIH guidelines. The clinical significance of these findings remains to be shown.

Aged↗
PubMed1999

Effect of topical ascorbic acid on free radical tissue damage and inflammatory cell influx in the cornea after excimer laser corneal surgery.

OBJECTIVE: To evaluate the effect of topical ascorbic acid on oxygen free radical tissue damage and the inflammatory cell influx in the cornea after excimer laser keratectomy. METHODS: Five New Zealand white rabbits underwent bilateral phototherapeutic keratectomy with the 193-nm argon fluoride excimer laser. Following treatment, the right eye of each rabbit was treated with 10% ascorbic acid every 3 hours for 24 hours. The left eyes served as controls. After 24 hours, all animals were killed and their corneas were trephined and processed. Sections were stained with fast blue B and with hematoxylin-eosin. Oxidative tissue damage in the form of lipid peroxidation was detected by fluorescent peroxidized carbonyl compounds using a confocal laser scanning microscope. The quantity of these compounds was determined using the National Institutes of Health digital image analysis system. Statistical comparisons of lipid peroxidation and polymorphonuclear cell count between the ascorbic acid groups and the controls were performed using the Student t test. RESULTS: Lipid peroxidation and polymorphonuclear cell counts were significantly decreased in the superficial cornea of ascorbic acid-treated eyes compared with control eyes (P <.03 and <.02, respectively). CONCLUSIONS: Topical ascorbic acid application decreased oxygen radical tissue damage following excimer keratectomy; moreover, topical application of ascorbic acid was shown to reduce the acute inflammatory reaction efficiently. This suggests that topical ascorbic acid could be considered a complementary treatment in the pharmacological modulation after excimer laser corneal surgery. CLINICAL RELEVANCE: Corneal opacity may complicate excimer keratectomy. The use of an antioxidant to reduce tissue damage could help minimize postoperative stromal opacification.

Administration, Topical↗
PubMed2003

A contact lens as an artificial cornea for improved visualization during practice surgery on cadaver eyes.

OBJECTIVE: To describe the use of a polymethylmethacrylate contact lens as an artificial cornea to enhance visualization for practice surgery using cadaver eyes. DESIGN: The opaque cornea of a cadaver eye is removed by trephination. Cyanoacrylate glue is used to secure a large-diameter polymethylmethacrylate contact lens to the corneal rim. RESULTS: Excellent visualization for practice surgery is achieved with this technique. The adhesion of the contact lens to the cadaver eye maintains the anterior chamber sufficiently to perform phacoemulsification cataract extraction or pars plana vitrectomy. CONCLUSIONS: This technique improves visualization of the intraocular structures during practice surgery, thereby enhancing the ability of the learning surgeon to perform and practice delicate surgical maneuvers. The procedure is simple, effective, and inexpensive.

Cadaver↗
PubMed2003

Risk factors for various causes of failure in initial corneal grafts.

OBJECTIVE: To determine the risk factors for specific causes of initial corneal graft failure. METHODS: This study analyzed corneal graft survival rates in a longitudinal noncomparative case series of 3992 consecutive penetrating keratoplasties performed at a single large referral center. Regrafts (n = 352) were excluded from the analysis of risk factors for initial graft failure. Data were collected retrospectively from August 1, 1982, through December 31, 1986, and prospectively from January 1, 1987, through August 31, 1996. Patients were examined preoperatively, at 1, 3, 6, 9, 12, 18, and 24 months posttransplantation, and annually thereafter. Potential risk factors were evaluated individually by Kaplan-Meier survival analysis. Cox proportional hazards regression modeling was then used to investigate the impact of each independent variable, adjusted for the confounding influence of the other independent variables. RESULTS: The use of topical glaucoma medications was a significant risk factor for corneal graft failure by 3 major causes: rejection, endothelial decompensation without a documented immunologic reaction, and ocular surface disease. Deep stromal vascularization was an independent risk factor for rejection failure. Diabetes mellitus, peripheral anterior synechiae, recipient race, and small trephination size were significant risk factors for endothelial failure. CONCLUSION: Independent risk factors differentially impact specific causes of corneal graft failure.

Adolescent↗
PubMed2006

Modified microkeratome-assisted posterior lamellar keratoplasty using a tissue adhesive.

OBJECTIVE: To compare graft stability and astigmatic change using suture vs tissue adhesive in an experimental model of microkeratome-assisted posterior lamellar keratoplasty. METHODS: A 300-microm-thick partial flap keratectomy was performed in human donor corneoscleral rims using an artificial anterior chamber and a manual microkeratome. The flap stopped at the left central opening border, providing a wide hinge to add stability. After flap reflection, a 6.25-mm trephination was performed to obtain a disc of posterior stroma, Descemet membrane, and endothelium. The disc was positioned in a sutureless fashion, and the flap secured with either 5 interrupted sutures or a chondroitin-sulfate-aldehyde-based adhesive. Increasing intrachamber pressures were created to detect graft stability. Videokeratographic data were recorded to evaluate astigmatic change. RESULTS: The mean (SD) astigmatic change was 3.08 (0.84) diopters (D) in the sutured group and 1.13 (0.55) D in the glued group (P = .008). Mean (SD) resisted pressures were 95.68 (27.38) mm Hg and 82.45 (18.40) mm Hg in the sutured and glued groups, respectively (P = .97). CONCLUSION: This modified technique of microkeratome-assisted posterior lamellar keratoplasty showed excellent graft stability in both groups. Flaps sealed with the novel tissue adhesive had reduced astigmatic changes in our experimental model. CLINICAL RELEVANCE: Sutureless microkeratome-assisted posterior lamellar keratoplasty using tissue adhesive may become a new alternative in the surgical treatment of corneal endothelial disorders.

Aged↗
PubMed2006

Optimal size and location for corneal rotational autografts: a simplified mathematical model.

OBJECTIVE: To calculate clinical guidelines for the optimal location and size of a rotational autokeratoplasty. METHODS: The ideal graft size and trephine decentration for a rotational autograft were calculated based on scar location using geometric models. Mathematical variables were set to maximize postoperative visual acuity and for generalization of the geometric model. This model was used in a rotational autokeratoplasty of a patient with a history of a corneal scar and diplopia. An 8-mm autograft was decentered 0.5 mm superiorly and rotated 180 degrees to relocate the scar to the superior aspect of the cornea, out of the patient's vision. RESULTS: For cases that satisfy the given variables, a graft diameter of 8 mm with a decentration of 0.5 mm balances maximization of scar removal and scar movement superiorly, with minimization of discrepancy in corneal thickness after rotation. For scars that are alpha degrees from horizontal, the graft should be rotated 180 - alpha degrees . By using these calculations, the autograft in this case successfully resolved the diplopia and improved visual acuity. CONCLUSIONS: A rotational autograft can be an effective alternative to standard penetrating keratoplasty for some patients with corneal scars. We establish a mathematical model for most clinical instances of a rotational autograft, in which an 8-mm graft with a decentration of 0.5 mm best satisfies the goals of surgery.

Adult↗