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Management of full-thickness burns of the scalp and skull.

Full-thickness burn injury of the scalp, with or without necrosis of underlying bone, is a complex therapeutic problem. Inability to diagnose depth of injury, controversy regarding wound closure, and a high incidence of acute morbidity are all associated with it. We reviewed the records of 17 patients who had suffered such injury. Wound closure was accomplished by split-thickness autograft alone in three patients, by bone dermabrasion and split-thickness autograft in six, by bone excision and split-thickness autograft in five, and by immediate local rotation flap in three. Systemic and/or local septic complications developed in 50% of all patients who underwent bony debridement. When feasible, early excision followed by immediate flap coverage is the procedure of choice. It avoids the multiple operative procedures required by the more conservative approach to wound closure, thereby shortening the period of primary hospitalization and virtually eliminating the risk of sepsis.

Adolescent↗

Requiem for a heavyweight: the demise of scalp blood pH sampling.

Fetal scalp blood pH sampling has played a valuable role in the development of our understanding of fetal welfare in labor and in the interpretation of electronic fetal heart rate patterns. There is question as to the feasibility of retaining this practice in modern obstetric care because of the advance of science, the general reliance on fetal monitoring criteria for ascertaining fetal well-being, the logistic difficulties involved in obtaining accurate and timely samples, the economic consequences of having to maintain analytic equipment in working order in times of very infrequent use, and the poor correlation between pH alterations and predictable neurologic consequences in the child. As it has all but vanished from use in most clinical care centers, and the principal argument for retaining it ultimately references the physician as the beneficiary, the author proposes that it should be removed from any possible association with purported "standards of care."

Blood Specimen Collection↗

Polymicrogyria associated with scalp and limb defects: variant of Adams-Oliver syndrome.

We describe cortical malformations in two siblings who also had features of Adams-Oliver syndrome (AOS, MIM 100300). The parents were first cousins and showed no signs of either disorder, suggesting autosomal recessive inheritance. Psychomotor delay was present in both sibs, and cerebral imaging was indicative of polymicrogyria (PMG). One sib had aplasia cutis congenita of the scalp and transverse limb defects, and the other had short fingers and toes and also developed lymphedema of the right leg. CNS abnormalities and lymphatic abnormalities are rare manifestations of AOS, and we suggest that these sibs have a rare variant of AOS with probable recessive inheritance.

Abnormalities, Multiple↗

Microcephaly, cutis verticis gyrata of the scalp, retinitis pigmentosa, cataracts, sensorineural deafness, and mental retardation in two brothers.

We describe the cases of two brothers with microcephaly, primary cutis verticis gyrata of the scalp, prominent supraorbital ridges, large nose, hypertelorism, exotropia, progressive retinitis pigmentosa, cataracts, sensorineural hearing loss, kyphoscoliosis, and mental retardation. A review of the literature focusing on the major clinical findings suggests that our cases may represent a hitherto unreported new syndrome.

Abnormalities, Multiple↗

Bone resorption by macrophage polykaryons of a pilar tumor of scalp.

The nature of keratin-associated giant cells of a pilar tumor of scalp (PTS) was assessed for several osteoclast-like characteristics, including antigenic phenotype, ultrastructure, calcitonin response, and bone resorbing ability. The giant cells, unlike osteoclasts, did not respond morphologically to calcitonin, had the antigenic phenotype of cells of the monocyte/macrophage lineage, and showed ultrastructural features of macrophage polykaryons. However, like osteoclasts, the giant cells were capable of bone resorption, including resorption pit formation. This indicates that the giant cells in PTS are of histiocytic and not osteoclastic differentiation. Bone resorption by tumor-associated macrophage polykaryons shows that this is not a unique defining characteristic of osteoclasts. It also suggests that such histiocytic cells may contribute to the osteolysis associated with skeletal metastases of squamous and other carcinomas.

Aged↗

Autosomal dominant inheritance of scalp defects with ectrodactyly.

Nine members of four generations of a kindred had an autosomal dominant syndrome in which congenital scalp defects were associated with abnormalities of the hands and feet. Radiographically apparent, circumscribed defects of the skull were an additional inconsistent feature. Genetic counseling is made difficult by varying phenotypic expression of the gene.

Adolescent↗

In utero brain destruction resulting in collapse of the fetal skull, microcephaly, scalp rugae, and neurologic impairment: the fetal brain disruption sequence.

Three infants are reported with a recognizable pattern of defects consisting of severe microcephaly, overlapping sutures, prominence of the occipital bone, and scalp rugae. This condition, which we think represents microhydranencephaly, appears to be produced by partial brain destruction during the second or third trimester, diminution in intracranial hydrostatic pressure, and subsequent collapse of the fetal skull. Several different causes for this condition have been suggested including partial disruption of the blood supply to the brain and prenatal viral infection.

Adult↗

Scalp and limb defects with cutis marmorata telangiectatica congenita: Adams-Oliver syndrome?

We report on a boy with congenital scalp and limb defects, consistent with a diagnosis of Adams-Oliver syndrome (aplasia cutis congenita with terminal transverse limb defects). An additional finding present in this child and in his mother was cutis marmorata telangiectatica congenita. Although this boy fits the diagnostic criteria for Adams-Oliver syndrome, his mother does not. We discuss whether this condition is highly variable, or heterogeneous.

Abnormalities, Multiple↗

Aicardi syndrome, metastatic angiosarcoma of the leg, and scalp lipoma.

An infant girl with Aicardi syndrome, scalp lipomas, and angiosarcoma of a limb is reported. The cavernous hemangioma of the leg was benign when biopsied at age 5 months but became malignant at 11 months. Angiosarcoma caused multiple distant metastases which were evident at autopsy at age 19 months. This is the first case of Aicardi syndrome associated with lipoma and metastatic angiosarcoma.

Eye Abnormalities↗

Scalp EEG for the diagnosis of epilepsy and photosensitivity in the baboon.

Spontaneous seizures have been observed in several baboon species housed at the Southwest National Primate Research Center (SNPRC), including Papio hamadryas anubis and cynocephalus/anubis, hamadryas/anubis, and papio/anubis hybrids. The goal of this study was to establish a noninvasive, reliable electroencephalographic technique to characterize epilepsy phenotypes and assess photosensitivity in these subspecies. Thirty baboons with witnessed seizures, and 15 asymptomatic baboons underwent scalp electroencephalograms (EEGs) with photic stimulation (PS). The sensitivity and specificity of surface EEG for identifying interictal epileptic discharges (IEDs) in baboons with witnessed seizures were examined. The morphology of IEDs, electroclinical features of seizures and responses to PS, reproducibility of EEG findings, and intrarater reliability were also evaluated. Twenty-three seizure baboons (77%) demonstrated IEDs, predominantly with frequencies of 4-6 Hz in 18 baboons and 2-3 Hz in six baboons. Two seizure animals had a mixture of 2-3-Hz and 4-6-Hz IEDs. All animals with 2-3-Hz IEDs were 3 years old or younger. Myoclonic seizures (MS) and generalized tonic-clonic seizures (GTCS) were recorded in 13 baboons (43%). PS activated IEDs in 15 baboons (50%) and seizures in nine baboons. The presence of IEDs or seizures was not associated with a particular gender or species (Fisher exact test, alpha=0.05). Seizures were more common in animals >3 years old, while PS-induced IEDs and seizures were more prevalent in P.h. anubis/cynocephalus crosses compared to P.h. anubis. In the asymptomatic controls, IEDs were recorded in five baboons (33%), and photoparoxysmal responses were observed in two (13%). Surface EEG is a sensitive and reliable instrument for characterizing the epilepsy encountered in Papio species. Electroclinically, the seizure animals had generalized epilepsy with photosensitivity. The variation in IED morphology may be age-related or it may reflect different epileptic phenotypes. Ketamine provoked IEDs and seizures in most seizure animals and only in a few asymptomatic baboons; therefore, it may enhance the sensitivity of surface EEG for detecting a predisposition to epilepsy.

Animals↗

Intractable partial epilepsy following low-dose scalp irradiation in infancy.

We report the development of intractable epilepsy in 3 patients treated with irradiation to "strawberry" scalp nevi in infancy. Low-dose radiation was used (12 and 13 Gy in 2 of the patients). The clinical evolution suggested a recognizable and distinctive postradiation syndrome. There was concordance between the site of radiation as shown by localized alopecia, the clinical features of the partial seizures, and electrographic abnormalities. The clinical picture was unlike delayed cerebral radiation necrosis of adulthood, which is not thought to occur at doses below 50 Gy, in 2-Gy fractions. Neurological deficits were not progressive and in 2 patients there was no evidence of parenchymal injury on cranial magnetic resonance imaging scanning. These differences suggest pathogenetic differences to cerebral radiation injury of adulthood, probably relating to the interaction between nervous system development, individual susceptibility, and the low doses of radiation employed.

Adolescent↗

Accuracy and applications of group MEG studies using cortical source locations estimated from participants' scalp surfaces.

We contend that powerful group studies can be conducted using magnetoencephalography (MEG), which can provide useful insights into the approximate distribution of the neural activity detected with MEG without requiring magnetic resonance imaging (MRI) for each participant. Instead, a participant's MRI is approximated with one chosen as a best match on the basis of the scalp surface from a database of available MRIs. Because large inter-individual variability in sulcal and gyral patterns is an inherent source of blurring in studies using grouped functional activity, the additional error introduced by this approximation procedure has little effect on the group results, and offers a sufficiently close approximation to that of the participants to yield a good indication of the true distribution of the grouped neural activity. T1-weighted MRIs of 28 adults were acquired in a variety of MR systems. An artificial functional image was prepared for each person in which eight 5 x 5 x 5 mm regions of brain activation were simulated. Spatial normalisation was applied to each image using transformations calculated using SPM99 with (1) the participant's actual MRI, and (2) the best matched MRI substituted from those of the other 27 participants. The distribution of distances between the locations of points using real and substituted MRIs had a modal value of 6 mm with 90% of cases falling below 12.5 mm. The effects of this approach on real grouped SAM source imaging of MEG data in a verbal fluency task are also shown. The distribution of MEG activity in the estimated average response is very similar to that produced when using the real MRIs.

Adult↗

Total upper lip reconstruction with a free temporal scalp flap: long-term follow-up.

BACKGROUND: In men, reconstruction of large full-thickness defects of the upper lip requires both an inner layer to replace the mucosal lining and an outer hair-bearing layer. METHODS: When locating the superficial temporal vessels, the design of the temporal flap is marked following the hairline needed. After meticulously dissecting the flap, it is inset and microanastomosed with the facial blood vessels. The internal mucosal layer of the flap is grafted on. During the follow-up period, the sensory recovery and motor functions are examined and recorded. RESULTS: The postoperative courses were uneventful, and patients were satisfied with the results. One patient has a long follow-up period of 18 years. CONCLUSIONS: The free temporal scalp hair-bearing flap offers a reasonable alternative to conventional techniques in the reconstruction of large defects of the male upper lip or even a total upper lip. It is a single-staged, relatively simple method of providing hair-bearing skin to the upper lip.

Adult↗

Surgical management of advanced scalp cancer.

A series of 53 advanced scalp cancer patients treated with surgery is presented. A review of these patients concludes: 1) local tumor growth--not distant metastasis--is the primary problem; 2) management is based on the tendency of a tumor to spread laterally early in its development with a deep invasion occurring later on; 3) when deep invasion occurs, radical excision and reconstruction is indicated to control the disease; 4) recurrence following adequate local therapy requires a change in treatment modality.

Adult↗

Correlation of ominous fetal heart rate pattern and scalp blood pH with one-minute Apgar score.

Fetal minitoring data were analyzed in 176 labors that developed ominous fetal heart rate deceleration patterns (FHRDP) during the two hours prior to delivery in an effort to identify how neonatal condition could be most accurately predicted. It was found that ominous FHRDP corresponded to a one-minute Apgar score of 6 or less in only 15.3% of cases. When patterns with fetal scalp blood pHs (FSBpH) of less than or equal to 7.20 (n = 18) were considered, 44.4% had an Apgar score of 6 or less. Mean Apgar scores for those neonates who had a pH of less than or equal to 7.20 were significantly less than the mean Apgar score of the control group (p less than 0.001 for all deceleration types). The result reveals that FSBpH has a better predictive value than FHRDP alone for neonatal depression. It is suggested that, as soon as ominous FHRDP occurs during labor, FSBpH be performed to assess not only fetal status but also to predict neonatal outcome.

Apgar Score↗