A 34-year-old male sustained a unilateral avulsion fracture through the origin of the transverse atlantal ligament following a road traffic accident. This was successfully treated in a rigid neck collar for 8 weeks. Injuries to the transverse atlantal ligament are often associated with significant bony injury and atlanto-axial instability. Isolated injuries to the transverse ligament are extremely rare and the present case suggests that a trial of conservative management may be worth pursuing.

OBJECT:Apoptosis has increasingly been implicated in the pathobiology of traumatic brain injury (TBI). The present study was undertaken to confirm the presence of apoptosis in the periischemic zone (PIZ) of traumatic cerebral contusions and to determine the role of apoptosis, if any, in neurological outcome.METHODS:Brain tissue harvested at Wentworth Hospital from the PIZ in 29 patients with traumatic supratentorial contusions was compared with brain tissue resected in patients with epilepsy. Immunohistochemical analyses were performed on the tissues to see if they contained the apoptosis-related proteins p53, bcl-2, bax, and caspase-3. The findings were then correlated to demographic, clinical, surgical, neuroimaging, and outcome data. In the PIZ significant increases of bax (18-fold; p < 0.005) and caspase-3 (20-fold; p < 0.005) were recorded, whereas bcl-2 was upregulated in only 14 patients (48.3%; 2.9-fold increase) compared with control tissue. Patients in the bcl-2-positive group exhibited improved outcomes at the 18-month follow-up examination despite an older mean age and lower mean admission Glasgow Coma Scale score (p < 0.03). Caspase-3 immunostaining was increased in those patients who died (Glasgow Outcome Scale [GOS] Score 1, 12 patients) when compared with those who experienced a good outcome (GOS Score 4 or 5, 17 patients) (p < 0.005). Regression analysis identified bcl-2-negative status (p < 0.04, odds ratio [OR] 5.5; 95% confidence interval [CI] 1.1-28.4) and caspase-3-positive status (p < 0.01, OR 1.4, 95% CI 1.1-1.8) as independent predictors of poor outcome. No immunostaining for p53 was recorded in the TBI specimens.CONCLUSIONS:The present findings confirm apoptosis in the PIZ of traumatic cerebral contusions and indicate that this form of cell death can influence neurological outcome following a TBI.

A case of delayed intracerebral abscess due to Proprionibacterium acnes (P. acnes), 18 months after an uneventful excision of a parasagittal haemangiopericytoma in a 61-year-old female is reported. This is highly unusual as cerebral abscess by P. acnes is rare and it occurred so late postoperatively in the absence of known risk factors. We propose the inclusion of cerebral abscess by P. acnes in the differential diagnosis of lesions that mimic tumour recurrences, after clean craniotomies.

Patients with acute brain pathology requiring ferromagnetic bio-medical implants for on-going invasive monitoring are largely excluded from the benefits of MRI scanning. We evaluated the behaviour of a thermal diffusion cortical blood flow (TD-CBF) sensor both in vitro (phantom gelatin model) and in vivo environments in a high field strength MRI system. Two baboons underwent cranial subdural implantation of 2 TD-CBF sensors/hemisphere and a single left parietal sensor was implanted subcortically to determine any deleterious effects. Using standard MRI sequences, artefact size, thermal effects, current generation, movement and reliability of recordings were assessed during scanning. The deflection forces were negligible, no observable thermal effects were demonstrated, while wide fluctuations in cerebral blood flow recordings were recorded. Mean image artefact size for implanted sensors was 6 times larger than in vitro. Patients with an implanted TD-CBF sensor may be safely imaged provided the device is disconnected. The MRI images obtained are of an acceptable quality.

OBJECTThe presence of the apolipoprotein E-epsilon4 (APOE-epsilon4) allele is reported to be associated with poor outcome after traumatic brain injury (TBI). This study was performed to determine if the presence of the APOE-epsilon4 allele influenced outcome in a cohort of black patients with TBI who had homogeneous neuropathological findings.METHODSVenous blood was collected at the time of admission to determine the APOE genotype in black Zulu-speaking patients who presented with traumatic cerebral contusions. The frequency of the APOE-epsilon4 allele's appearance was correlated with outcome at a minimum of 6 months of follow up. Univariate and multivariate analyses were performed to determine independent risk factors and to control for confounding factors. In 110 black Zulu-speaking patients with traumatic cerebral contusions, genotypes for APOE were analyzed. Eleven of 45 (24.4%) with the APOE-epsilon4 allele experienced a poor outcome, compared with 10 (15.4%) of 65 without this allele (p = 0.34). Both patients with homozygous APOE-epsilon4 alleles experienced a good outcome (Glasgow Outcome Score 5). Univariate and multivariate analysis revealed no significant relationship in patients with the APOE-epsilon4 allele with regard to age, admission Glasgow Comas Scale score, contusion volume, type of neurosurgical management, and outcome. The risk of a poor outcome was, however, greater in patients with the APOE-epsilon4 allele (relative risk 1.59; 95% confidence interval 0.74-3.42).CONCLUSIONSThe authors recorded no relationship between APOE-epsilon4 allele status and outcome after TBI in black patients. Given the high regional susceptibility to the APOE gene, further studies, possibly even community-based investigations and studies conducted in other geographic areas, are probably warranted.

Apolipoprotein E (APOE) is thought to be responsible for the transportation of lipids within the brain, maintaining structural integrity of the microtubule within the neurone, and assisting with neural transmission. Possession of the APOE epsilon4 allele has also been shown to influence neuropathological findings in patients who die from traumatic brain injury, including the accumulation of amyloid beta protein. Previous clinical studies reporting varying outcome severities of traumatic brain injury, including cognitive and functional recovery, all support the notion that APOE epsilon4 allele possession is associated with an unfavourable outcome. Evidence from experimental and clinical brain injury studies confirms that APOE plays an important role in the response of the brain to injury.

OBJECTStaphylococcus species are the most common organisms responsible for infection following implantable cerebrospinal fluid (CSF) diversionary procedures. The role of an antibiotic-impregnated shunt (AIS) system in the prevention of shunt infection has remained unclear because no human clinical trial has been reported on thus far. In this study, the authors assess an AIS system with respect to its prevention of shunt infection.METHODSPatients were prospectively randomized into groups to evaluate the efficacy of an AIS system against an identical control shunt system. The data accrued were subjected to a detailed statistical analysis. Logistic regression analysis was performed to determine the independent association between outcome and predictor variables. Shunt function analysis was also performed to compare the average time to infection between the two groups. One hundred ten patients were recruited; 60 received control shunt systems and 50 received AIS systems. Thirteen shunt infections were recorded (10 in the control group and three in the AIS group). Nine (69%) of 13 infections occurred within 2 months after shunt implantation (eight of 10 in the control group and one of three in the AIS group). Apart from one patient in whom no organism was identified, a total of 14 organisms (12 patients) were cultured from either the CSF (nine) or the shunt apparatus (three). Staphylococcus species accounted for the majority of shunt infections (83%): all 10 control shunts were found to have a positive culture of staphylococci, whereas none of the AISs had any staphylococci (p = 0.038).CONCLUSIONSThe AIS afforded antistaphylococcal protection, especially during the early postoperative period when most shunt infections are known to occur and throughout the follow-up period (median 9 months). The AIS system represents another important tool to enable the neurosurgeon to prevent shunt infections.

BACKGROUND Craniocerebral missile injuries have steadily increased to become the most common form of penetrating neurotrauma in our environment resulting in continued morbidity and neuropsychological sequelae. Civilian infratentorial gunshot injuries are uncommon but generally regarded as fatal injuries, with many patients dying before reaching hospital.METHODS A retrospective analysis of 1,069 patients with civilian gunshot wounds (GSW), admitted to our unit over a 14-year period (1986-2000), identified 26 patients with infratentorial gunshot injuries (2.4%). A detailed analysis of these patients was carried out, which included demographic factors, clinical and anatomic correlation, computed tomography scans, surgical management, and outcome.RESULTS All patients were male. The mean age was 26.5 +/- 11.5 years and the mean admission Glasgow Coma Score 11.8 +/- 2.7. Twenty-four of 26 patients required cerebrospinal fluid (CSF) diversion to control secondary hydrocephalus. The second commonest surgical procedure was posterior fossa decompression. Five of 26 patients died (19.2%). Severe morbidity was noted in 9 of 21 surviving patients (42.8%). Significant predictors: good outcome was associated with primary missile entry of the infratentorial compartment (p = 0.005), while patients with supratentorial to infratentorial missile trajectory were noted to have a poorer outcome (p = 0.041).Location of cerebellar injury (lateral or medial) and missile caliber had no significant influence on patient outcome.CONCLUSION Early control of incipient or established hydrocephalus and aggressive surgical management where appropriate, with careful postoperative monitoring, is necessary for good outcome in patients with civilian infratentorial missile injuries. (C) 2002 by Elsevier Science Inc.

BACKGROUND Previous studies have demonstrated that rhinogenic subdural empyema (SDE) generally has a good prognosis. Most patients are admitted with an altered level of consciousness or significant neurological deficit, but eventually have a good outcome. It is well known that intra-operative brain swelling may occur with subdural empyema. OBJECTIVE To define cerebral blood flow (CBF) dynamics and determine the role of cerebral hyperaemia, if any, in intracranial SDE. METHODS CBF dynamics were assessed in five patients (mean age 13.2 +/- 2.2 years) with unilateral rhinogenic convexity SDE documented on computer tomography (CT). Regional cortical blood flow (rCBF) was measured using a thermo-coupled sensor placed on the cortex at the time of surgery. Dynamic CT scans were performed to assess cerebral blood volume (CBV) quantitatively, while transcranial Doppler ultrasonography (TCD) was used to measure cerebral blood flow velocities (CBF velocities) both pre- and post-operatively for 21 days. The opposite 'normal' hemisphere served as a control for each patient. RESULTS Post-operative rCBF and CBF velocities in the pathological hemisphere progressively increased to plateau at 96 hours. Cerebral blood volume was increased bilaterally, but to a greater extent in the pathological hemisphere and more so in grey than white matter. These haemodynamic changes, though clinically significant did not reach statistical significance (p>0.05). CONCLUSION Our results suggest that the accompanying brain swelling in rhinogenic SDE is a complex event, with reactive cerebral hyperaemia possibly playing neuroprotective role. Furthermore, unilateral convexity empyema causes bilateral cerebral haemodynamic changes. Future studies are necessary to define the aetiology of brain swelling in intracranial SDE.

A 15-year (1983-1997) review of our unit's computed tomographic experience with traumatic cranial empyema (TCE) is reported. Fifty-five patients with documented history and clinical evidence of neurotrauma with secondary cranial empyema at surgery were identified. The clinical records and CT scans were analysed. TCE [four extradural and 51 subdural collections (SDE)] accounted for 7.86% of the total cranial empyemas seen during the study period. Most of the patients were young males (44 patients) and neurological deficits on admission were found only in the SDE group. Forty-one of 53 patients presented with septic compound skull fractures. Fifty-four patients had urgent surgical drainage. Eighty per cent of patients experienced a good outcome (GOS 4 or 5). A morbidity of 16. 4% ( including postoperative seizures) was noted and eight patients died (mortality rate 14.5%). Urgent surgical drainage, removal of osteitic bone, wound debridement and high dose intravenous antibiotic therapy form the mainstay of treatment.

BACKGROUND:Previous studies have described the elaboration of cytokines in experimental models of congenital hydrocephalus using rats or mice. However, there have been no reports of similar studies in humans.OBJECTIVE:To determine the cytokine expression pattern in the cerebrospinal fluid (CSF) of patients with treated congenital hydrocephalus.DESIGN:A prospective study.SETTING:Wentworth Hospital, Durban, South Africa.SUBJECTS:Five patients (three infants and two older patients) with congenital hydrocephalus treated by means of a ventriculoperitoneal shunt.INTERVENTIONS:Immunophenotyping of peripheral blood was performed on a flow cytometer. The isolation, in-vitro stimulation of peripheral blood and CSF mononuclear cells, and intracellular cytokine determination by flow cytometry were performed.MAIN OUTCOME MEASURES:Peripheral blood and CSF cytokine measurements.RESULTS:Although not statistically significant, all measured mean cytokine levels in the peripheral blood of the infant group were consistently higher than that of the adult group. CSF cytokine levels in both groups were similar and unremarkable.CONCLUSION:No clear pattern of CSF cytokine elaboration, either type-1 (T helper 1) (Th1) or Type-2 (T helper 2) (Th2), could be demonstrated in either of the groups. The significance of higher peripheral blood cytokine levels in the infants is unclear, but may be age-related, and is not apparent in the CSF.

Focal cerebral contusions can be dynamic and expansive, leading to delayed neurological deterioration. Due to the high mortality associated with such cerebral contusions, our standard practice had evolved into evacuating contusions in patients who had a deterioration in level of consciousness, lesions>30 cc and CT suggestion of raised ICP. Experimental brain edema studies have implicated kinins in causing 2° brain swelling. CP-0127 (Bradycor TM), a specific bradykinin antagonist, has been found to reduce cerebral edema in a cold lesion model in rats. In a randomized, single blind pilot study, a 7 day infusion of CP-0127 (3.0 ug/kg/min) was compared to placebo in patients with focal cerebral contusions presenting within 24–96 hours of closed head injury with an initial GCS 9–14. The ICP, GCS, and vital signs were monitored hourly. The total lesion burden (TLB) was measured on serial CT scans.

The acute effects of a newly synthesized thromboxane dual blocker (KDI-792), a combined thromboxane synthase inhibitor and receptor antagonist, on lower limb circulation were examined using two-dimensional color and pulse Doppler ultrasonography and laser Doppler flowmetry. A randomized single-masked, placebo-controlled trial was performed on 36 type 2 diabetic patients with minimally impaired baseline flow. The anatomical cross-sectional area (CSA), maximum flow velocity (MFV) and flow volume index (FVI) in the right dorsal pedis artery (DPA) and right femoral artery (FA) were determined by Doppler ultrasonography before and 45 and 90 minutes after the administration of either 100 or 200 mg of KDI-792 to the dose groups or placebo to the control group. Periflux blood flow (PBF) in the right foot was determined simultaneously by laser Doppler flowmetry. Both CSA and MFV in the dose groups were significantly increased in both the FA and DPA. FVI was markedly increased from 21.4 ± 3.7 to 68.3 ± 26.8 in the DPA (M ± SD, P < 0.01) and from 365.4 ± 35.3 to 771.7 ± 75.7 in the FA (P < 0.01) in the 200 mg dose group. In the 100 mg dose group, FVI was markedly increased from 20.0 ± 8.7 to 68.3 ± 26.8 (P < 0.01) in the DPA and from 372.5 ± 130.0 to 677.5 ± 187.8 (P < 0.01) in the FA. PBF was also increased in both dose groups (from 4.15 ± 1.4 to 7.0 ± 4.0 ml/min/100 g tissue in the 200 mg dose group, P < 0.01), whereas there were no significant changes in either measurement in the control group. There were no significant changes in pulse rate or blood pressure after administration in either the dosage group or the placebo group. These and previous findings indicate that a single administration of KDI-792 markedly increases lower limb blood flow and might have a more potent vasodilating effect than that of prostaglandin I2 derivatives.

To report a minimally invasive, nontubular endoscopic technique to resect intraparenchymal brain tumors and assess the feasibility, safety, and surgical resection margins achievable by this novel technique.Over a 21-month period, 48 patients underwent 50 consecutive endoscopic intraparenchymal tumor resections. Data on surgical morbidity and mortality and length of stay were collected prospectively. The percentage of surgical resection and residual tumor volumes were calculated using preoperative and postoperative volume computed tomography or magnetic resonance imaging. All tumors were resected through a 2-cm minicraniotomy using a high-definition rigid endoscope with a 30-degree viewing angle. Bimanual resection was performed using standard microsurgical technique.Mean patient age was 53 years. There were 42 supratentorial (19 frontal, 17 temporal, 3 occipital, 1 parietal, and 2 parafalcine) tumors and 8 infratentorial tumors. Mean tumor volume was 41 cm3. There were 12 metastases, 24 glioblastomas, 4 World Health Organization grade III gliomas, 5 World Health Organization grade I–II gliomas, 3 meningiomas, and 2 hemangioblastomas. On volumetric analysis, the overall mean percent resection was 96%. In 70% of cases, >95% resection was achieved; total resection was achieved in 48% of cases. At 30 days postoperatively, there was 1 new postoperative neurologic deficit; there were no deaths during this period.Our experience demonstrates that resection of intraparenchymal tumors using a minimally invasive endoscopic technique is technically feasible and safe, achieves good tumor resection margins, and has some potential advantages over a traditional microscopic technique.

OBJECTIVE:To determine whether the establishment of a peripheral computed tomography (CT) facility has an influence on the central referral neurosurgical unit, and particularly whether unnecessary referrals are avoided.DESIGN:The outpatient records of all patients referred from Umtata General Hospital (UGH) to the neurosurgical unit at Wentworth Hospital, Durban, were retrospectively analysed over a 4-year period--2 years before and 2 after the introduction of CT facilities at UGH.SETTING:Wentworth Hospital, Durban, which houses the sole neurosurgical referral centre for the region.PATIENTS:Eight hundred and forty patients were referred to the neurosurgical unit from UGH during the 4-year study period--July 1990 to June 1994.MAIN OUTCOME MEASURES:1. The number of referrals to the neurosurgical unit before and after introduction of peripheral CT facilities at UGH. 2. The admission rate of the above referrals during the same periods, indicating appropriate referrals.RESULTS:1. There were 536 patients referred from UGH to the neurosurgical unit over a 2-year period before the introduction of peripheral CT facilities, and 304 patients during the subsequent 2-year period after introduction of CT facilities at UGH. This represented a 43.3% decrease in patient referrals during a period in which referrals from all other areas increased by 2.6%. 2. The admission rate of patients (indicating appropriate referrals) being referred from UGH increased from 46.3% before CT facilities to 79.9% after the introduction of peripheral CT facilities. The admission rate of patients from other areas, excluding UGH, during the same periods, decreased from 50.3% to 46.4%.CONCLUSION:This audit reveals that following the introduction of CT facilities at UGH, the number of referrals to Wentworth Hospital's neurosurgical unit decreased by almost half (43.3%). Furthermore, the patients referred after introduction of the peripheral CT facility were more likely to be appropriate referrals (79.9%) than before (46.4%). Therefore, the provision of CT facilities at peripheral hospitals may effectively serve to exclude those patients who would otherwise be referred unnecessarily, and enable earlier referral of those patients who require urgent care at a tertiary neurosurgical unit.

Almost all peduncular hallucinations have been described in patients with intrinsic lesions of the midbrain. An as yet unreported case of peduncular hallucinosis caused by posterior compression of the midbrain by a medulloblastoma in a 16-year-old boy is provided. The hallucinations and associated symptoms only ceased after removal of the tumor.