Background We investigated the understudied anatomical variations of the superior petrosal vein (SPV) complex (SPVC), which may play some role in dictating the individual complication risk following SPVC injury. Methods Microvascular decompressions of the trigeminal nerve between September 2012 and July 2016. All operations utilized an SPVC preserving technique. Preoperative balanced fast field echo (bFFE) magnetic resonance imaging, or equivalent sequences, and operative videos were studied for individual SPVC anatomical features. Results Applied imaging and operative SPVC anatomy were described for fifty patients (mean age, 67.18 years; female sex and right-sided operations, 58% each). An SPVC component was sacrificed intentionally in 6 and unintentionally in only 7 cases. Twenty-nine different individual variations were observed; 80% of SPVCs had either 2 SPVs with 3 or 1 SPV with 2, 3, or 4 direct tributaries. Most SPVCs had 1 SPV (64%) and 2 SPVs (32%). The SPV drainage point into the superior petrosal sinus was predominantly between the internal auditory meatus and Meckel cave (85.7% of cases). The vein of the cerebellopontine fissure was the most frequent direct tributary (86%), followed by the pontotrigeminal vein in 80% of SPVCs. Petrosal-galenic anastomosis was detected in at least 38% of cases. At least 1 SPV in 54% of the cases and at least 1 direct tributary in 90% disturbed the operative field. The tributaries were more commonly sacrificed. Conclusions The extensive anatomical variation of SPVC is depicted. Most SPVCs fall into 4 common general configurations and can usually be preserved. BFFE or equivalent sequences remarkably facilitated the intraoperative understanding of the individual SPVC in most cases.
Background: The Brain Trauma Foundation's 2006 surgical guidelines have objectively defined the epidural hematoma (EDH) patients who can be treated conservatively. Since then, the literature has not provided adequate clues to identify patients who are at higher risk for EDH progression (EDHP) and conversion to surgical therapy. The goal of our study was to identify those patients. Methods: We carried a retrospective review over a 5-year period of all EDH who were initially triaged for conservative management. Demographic data, injury severity and history, neurological status, use of anticoagulants or anti-platelets, radiological parameters, conversion to surgery and its timing, and Glasgow Outcome Scale were analyzed. Bivariate association and further logistic regression were used to point out the significant predictors of EDHP and conversion to surgery. Results: 125 patients (75% of all EDH) were included. The mean age was 39.1 years. The brain injury was mild in 62.4% of our sample and severe in 14.4%. Only 11.2% of the patients required surgery. Statistical comparison showed that younger age (p < 0.0001) and coagulopathy (p = 0.009) were the only significant factors for conversion to surgery. There was no difference in outcomes between patients who had EDHP and those who did not. Conclusions: Most traumatic EDH are not surgical at presentation. The rate of conversion to surgery is low. Significant predictors of EDHP are coagulopathy and younger age. These patients need closer observation because of a higher risk of EDHP. Outcome of surgical conversion was similar to successful conservative management.RÉSUMÉ: Hématome épidural traité de façon conservatrice : quand s'attendre au pire. Contexte : Les lignes directrices chirurgicales de la Brain Trauma Foundation de 2006 ont défini objectivement les patients atteints d'un hématome épidural (HÉD) qui peuvent être traités de façon conservatrice. Depuis lors, il n'existe pas dans la littérature d'indices adéquats pour identifier les patients qui sont à plus haut risque de progression de l'HÉD et chez qui un traitement chirurgical doit être envisagé. Le but de notre étude était d'identifier ces patients. Méthode : Nous avons effectué une revue rétrospective sur une période de 5 ans des dossiers de tous les patients atteints d'un HÉD qui ont été assignés initialement au traitement conservateur. Nous avons analysé les données démographiques, la sévérité de la lésion et son historique, l'état neurologique, la prise d'anticoagulants ou d'antiplaquettaires, les paramètres radiologiques, le recours à un traitement chirurgical et le moment où il a été réalisé ainsi que le score au Glasgow Outcome Scale. L'analyse bivariée ainsi que l'analyse de régression logistique ont été utilisées pour déterminer les facteurs de prédiction significatifs de la progression de l'HÉD et du recours à la chirurgie. Résultats : Cent vingt-cinq patients (75% des patients atteints d'un HÉD) ont été inclus dans l'étude. L'âge moyen des patients était de 39,1 ans. La lésion cérébrale étai...
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