Decompressive craniectomy is a life-saving procedure used in the treatment of medically refractory intracranial hypertension in patients suffering from traumatic brain injury, cerebral infarction, subarachnoid hemorrhage (SAH), and intracerebral hemorrhage (ICH). 1,8,9,14 Indications for cranioplasty are usually protective and cosmetic. Cranioplasty has also been reported to facilitate neurological recovery 3,15 and improve cerebral blood flow, CSF hydrodynamics, and metabolic activity after a decompressive craniectomy.2-7 Some patients with severe brain swelling treated with decompressive craniectomy may develop communicating hydrocephalus, with or without persistent brain bulging. Consequently, these patients also require a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus.There is no consensus as to the timing of the cranioplasty and VP shunt placement in patients who require both operations. A large cranial defect could lead to turbulence in CSF circulation hydrodynamics and cerebral blood perfusion due to exposure to atmospheric pressure, followed by hydrocephalus. 4-7 Cranioplasty and VP shunts each affect CSF circulation, but exactly how each operation affects it is as yet unknown. Thus, undergoing both operations at the same time may cause complications due to unexpected CSF circulation changes. In this study, we assessed the results of undergoing cranioplasty and VP shunting at the same time in patients with cranial defects and hydrocephalus. We hypothesized that the outcomes after simultaneous cranioplasty and VP shunting may be worse than those when the operations are performed at different times. Object. Some patients with severe brain swelling treated with decompressive craniectomy may develop hydrocephalus. Consequently, these patients require cranioplasty and a ventriculoperitoneal (VP) shunt to relieve the hydrocephalus. However, there is no consensus as to the timing of the cranioplasty and VP shunt placement in patients requiring both. The authors assessed the results of performing cranioplasty and VP shunt placement at the same time in patients with cranial defects and hydrocephalus.Methods. A retrospective review was performed of 51 patients who had undergone cranioplasty and VP shunt operations after decompressive craniectomy for refractory intracranial hypertension between 2003 and 2012 at the authors' institution. Patient characteristics, data on whether the operations were performed simultaneously, brain bulging, hydrocephalus, cranial defect size, and complications were analyzed.Results. The overall complication rate was 43% (22 of 51 patients). In 32 cases, cranioplasty and VP shunt placement were performed at the same time. Complications included subdural hematoma, subdural fluid collection, and infection. The group undergoing cranioplasty and VP shunt placement at the same time had higher complication rates than the group undergoing the procedures at different times (56% vs 21%, respectively). The severity of complications was also greater in the former group. Patients with...

The crowned dens syndrome (CDS), also known as periodontoid calcium pyrophosphate dehydrate crystal deposition disease, is typified clinically by severe cervical pain, neck stiffness and atlantoaxial synovial calcification which could be misdiagnosed as meningitis, epidural abscess, polymyalgia rheumatica, giant cell arthritis, rheumatoid arthritis, cervical spondylitis or metastatic spinal tumor. Crystalline deposition on cervical vertebrae is less well known disease entity and only a limited number of cases have been reported to date. Authors report a case of CDS and describe the clinical feature.

The confluence of sinuses (CS; torcular herophili) is represented by the junction of the superior sagittal (SSS), straight (SS), occipital (OS), and two transverse sinuses (TS). The objective of this study was to interpret sinus flow around the CS by morphological investigation of the sinuses. This study is based on visual examination of dural venous sinuses in the region of the CS in 31 adult cadavers. In the inflow zone, we examined the direction of SSS and SS flow. In the communication zone, we examined the extent to which outflow sinuses communicate with other sinuses. In the outflow zone, we used the diameters of outflow sinuses to determine anatomical dominance. The SSS entered the CS via the right TS in 16 cases (51.6%) and via the center of the CS in 14 cases (45.2%). The SS entered via the center of the CS in 18 cases (58.1%) and via the left TS in 11 cases (35.5%). Outflow sinuses communicated freely in 26 cases (83.8%) and communicated partially in five cases (16.2%). Partial communication was the result of a septate CS. In terms of outflow, the right TS was dominant in 11 cases (35.5%), and in 18 cases (58.1%), outflow was symmetrical. The direction of SSS inflow was different from that of SS inflow, and partial communication was observed in five cases (16.1%). Therefore, the presence of a septum may be considered an anatomical factor, with implications in diagnosis or in the sacrifice of the outflow sinus of the CS.

The aim of this study is to investigate the factors that may be related to bone graft infection and to contribute to lower the infection rate. According to current studies, the rate of bone graft infection after cranioplasty was reported up to 15.9% and this is significantly high. There are many analyses of the factors influencing bone graft infection, but this issue may need to be reconsidered in that the current medical environment is ever-changing. Methods: We retrospectively reviewed the demographic, clinical data of 130 patients who underwent cranioplasty following decompressive craniectomy from January 2004 to December 2011. We analyzed several factors influencing bone graft infection and divided them into three categories of clinical, operation-related and hematological factors including white blood cell count, erythrocyte sedimentation rate, C-reactive protein and albumin. Statistical significance was done by chisquare test, Fisher's test and Mann-Whitney U test. Results: The infection occurred in 12 patients in 130 cranioplasties (9.2%). There was no difference in infection rate between each group of early and later surgery, graft material, cause of craniectomy. Among many factors, low Glasgow Coma Scale (GCS≤8) and combined ventriculoperitoneal (VP) shunt were significantly correlated with bone graft infection (p= 0.025, p=0.025, respectively). There was no statistically significant difference in hematological analysis between groups. Conclusion: Low GCS and combined VP shunt with cranioplasty may increase the risk of bone graft infection.

ObjectiveThe aim of this study was to compare the efficacy of indirect and combined bypass surgery for treatment of adult moyamoya disease (MMD). The definition of combined bypass surgery is a combination of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect anastomosis. Development of collateral circulation after surgery was investigated.MethodsForty three patients (58 hemispheres) with MMD were followed by cerebral angiography for at least six months after surgery, between May 2002 and July 2011. Indirect and combined revascularization surgeries were performed in 33 and 25 cases, respectively. Good outcome was defined as more than group B, in accordance with the method suggested by Matsushima.ResultsDevelopment of collateral circulation was not affected by sex (p = 0.493), clinical features (p = 0.206), or Suzuki stage (p = 0.428). Based on postoperative cerebral angiography, the combined bypass surgery group showed a better angiographic outcome, than the encephaloduroarteriomyosynangiosis (EDAMS) group (p = 0.100, odds ratio [OR] 4.107, 95% confidence interval [CI] 0.700 - 24.096). The combined bypass group showed a better response than the encephaloduroarteriogaleosynangiosis (EDAGS) group (p = 0.088, OR 4.600, 95% CI 0.721 - 29.332). Similar responses were observed for EDAGS and EDAMS (p = 0.886, OR 1.120, 95% CI 0.239 - 5.251). The combined bypass group showed a better response than the indirect group (p = 0.064, OR 4.313, 95% CI 0.840 - 22.130).ConclusionResults of this study demonstrate that combined bypass results in better revascularization on angiographic evaluation in adult MMD. Therefore, among surgical procedures, combined bypass is a choice that can be recommended.