The pathophysiology of malignant intracranial hypertension is a deleterious cycle of increased intracranial pressure, decreased tissue perfusion, declining intracellular energy production, increasing cellular edema, and subsequent increasing intracranial pressure. Decompressive craniectomy offers an effective treatment for intracranial hypertension that is refractory to standard medical treatment. There is no standardized technique suggested for durotomy and expansile duraplasty till date. We conducted this study on a model designed from locally available materials to objectively quantify the volume expansion achieved by the various durotomy and expansion duraplasty techniques. Amongst the more popularly used techniques for durotomy and duraplasty, the apparent volume expansion achieved appears to be maximum with a horse shoe shaped incision (43 ml) as opposed to a cruciate (30 ml) or a multipinnate (36 ml) incision. However, after correcting for the volume of the outpouchings, horse shoe shaped incision looses much of it's sheen (10 cm) lagging far behind the other two duraplasty techniques. Our study has proven the generally held view that there is not much to choose from between the cruciate and multipinnate durotomy techniques in performing expansile duraplasty. A horse shoe shaped durotomy on the other hand appears to be far less fruitful.
Current body of evidence suggests that the maintenance or enlargement of chronic subdural hematoma (cSDH) is caused by multiple factors. Inflammatory and vascular endothelial growth factor (VEGF)–induced accumulation of hematoma plays an important role in pathophysiology of cSDH. If neomembrane is implicated in the propagation of inflammatory mediators, excision of the culprit membrane becomes essential to treat and prevent recurrence of cSDH. This retrospective study was conducted in a service hospital where 48 cases of cSDH were operated in 2 years. Patients were evaluated clinically and radiologically. Surgical procedure offered included burr hole craniotomy (BHC), twist drill craniotomy (TDC), or craniotomy (Cr) with excision of neomembrane. Cr was offered whenever there was suspicion or evidence of reaccumulation, solid or calcified hematoma formation, nonobliteration of the subdural space, or numerous thick membranes as were demonstrated in imaging. In Cr maximum part of outer neomembrane was excised and margins were coagulated. The excised outer neomembrane was sent for immunohistochemical examination to assess the VEGF expression. Depending on the VEGF expression as seen on the microscope, these expressions were grouped into weak, moderate, or strong VEGF expression. The study showed that cSDH patients with neomembrane formation benefit from Cr. The strong VEGF expression from the excised neomembrane further strengthens the proinflammatory VEGF theory propagation of cSDH. It further proves that excision of the culprit membrane is essential to prevent recurrences.
It is a rare and underdiagnosed entity. The adagium “one only sees what one knows” is certainly true in cases of Blake's pouch cyst, as all types of posterior fossa cysts and cyst-like malformations may present nearly identical on initial imaging studies. Only one case of Blake's pouch cyst has been reported from this country, except for a case in utero, in which a diagnosis of Blake's pouch cyst was made on prenatal ultrasound and later confirmed by MRI. In this report we describe a case of Blake's pouch cyst in a 9-month-old male child along with the principles of diagnosis of Blake's pouch cyst, in combination with literature review. Differentiating Blake's pouch cyst from other posterior fossa cysts and cyst-like malformations and recognizing the accompanying hydrocephalus that are essentially noncommunicating have important implications not only on clinical management but also on genetic counseling, which is unnecessary in case of Blake's pouch cyst.
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