A modification of the supraorbital keyhole approach, the eyebrow incision-minisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 cm, that incorporates the orbital rim and roof and the frontal process of the zygomatic bone through an eyebrow incision. The orbital osteotomy facilitates view of the anterior and middle cranial fossa through the operating microscope, as well as the maneuverability of instruments through a small craniotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used successfully in elective surgery of 10 aneurysms of the anterior circulation. The mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tissue, reduced frontal lobe retraction, and an excellent postoperative cosmetic result. The approach is performed quickly by virtue of a limited skin incision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contraindications include the presence of a large frontal sinus, severe brain edema, and recent subarachnoid hemorrhage. In addition, this approach has not been used for the treatment of giant intracranial aneurysms.

Acute hemorrhagic leukoencephalitis (AHL) is characterized by an acute, rapidly progressive, monophasic, fulminant inflammatory hemorrhagic demyelination of white matter, usually postinfectious and associated with death or severe morbidity within a few days. 1-3 We report MRI and neuropathology in a case of AHL.Case report. A 19-year-old white man was admitted with acute onset of fever, headache, and progressive lethargy. He had developed mild upper respiratory symptoms and cough 2 weeks earlier.Examination showed lethargy and meningismus, but he was arousable and oriented to person, place, and time. Brainstem responses were intact. Serum white blood count was 17.9 cells/uL. Head CT (not shown) revealed a left parietal hypodensity with mild mass effect. He was started on levofloxacin, ceftriaxone, and dexamethasone treatment. Brain MRI (figure, A) was performed while the patient was able to communicate and brainstem function was intact. Six hours later, he had a cardiopulmonary arrest and required resuscitation, intubation, and mechanical ventilation, after which he lost all brainstem function. He was treated with mannitol and hyperventilation, yet he was declared brain dead 12 hours after resuscitation and pronounced dead another 3 hours later. Blood cultures were negative. Nasopharyngeal cultures and serum antigens were negative for Streptococcus Pneumoniae, Neisseria meningitidis, and Haemophilus influenza. On gross examination, autopsy showed that the brain was markedly swollen, weighing 1,810 grams, with uncal and tonsillar herniations and loss of gray-white demarcation, possibly related to "respirator brain." The deep white matter had a mottled gray appearance with posterior predominant focal hemorrhages, conforming to MRI lesions. Microscopic findings are shown (see figure, B).Discussion. By the combination of clinical, MRI, and pathology findings, this case is typical of AHL, which is usually triggered by infectious respiratory antigens. 1-3 The prodromal infection is usually followed 1 to 20 days later by the acute onset of symptoms and signs of meningitis and neurologic deficits (most commonly hemiparesis, aphasia, brainstem dysfunction, and seizures followed by coma and brain death). [1][2][3] AHL is felt to be a hyperacute form of the more common acute disseminated encephalomyelitis (ADEM); both seem to result from an autoimmune process directed against the CNS myelin. 3 The course of AHL is more fulminant than ADEM, with rapid progression that is more frequently fatal. 3 On MRI, the lesions of AHL tend to be larger and associated with more edema and mass effect 2,5,6 than in ADEM. 4 Perivenular demyelination and inflammation largely confined to the white matter are seen in both processes. The infiltrates in ADEM contain mostly lymphocytes, whereas AHL produces a predominantly neutrophilic infiltrate, with pericapillary ball and ring hemorrhages and hematomas.We report the third case in the literature of MRI findings in a patient with pathologically confirmed AHL. MRI in our patient showed confluent n...

There was no significant difference in the proportions of positive-outcome studies published in this sample of the emergency medicine literature compared with the general medicine literature. The potential impact of positive-outcome bias and methods of dealing with the problem are reviewed.

Congenital vertebral dislocation (CVD) is a rare congenital spinal malformation characterized by a translatory or rotatory vertebral displacement, or both, at a single level, that results in an abrupt angulation of the neural canal. The more caudal vertebra is dysplastic and appears at first glance to be posteriorly dislocated into the vertebral canal as a posterior hemivertebra, but is actually well aligned with the more caudal vertebral column. Unfortunately, the present classification of complex congenital vertebral anomalies is confusing, and CVD has been grouped together with other congenital vertebral malformations under the terms ‘segmental spinal dysgenesis’, ‘medial spinal aplasia’, and others. Moreover, a putative embryonic mechanism has never been proposed for CVD. Based upon our experience with 6 children and a critical review of the literature, we identify CVD as a distinct entity having characteristic anatomical features. We propose a novel putative embryonic mechanism – early embryonic ‘buckling’ – which likely occurs by the 6th embryonic week, prior to the period of axonal outgrowth and the beginning of vertebral chondrification.