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Most of the site will reflect the ongoing surgical activity of Prof. Munir Elias MD., PhD. with brief slides and weekly activity. For reference to the academic and theoretical part, you are welcome to visit  neurosurgery.tv

 

The patient  was transferred from another hospital due to progressing deterioration of his condition. He got insult 22-January-2005 for what he was admitted to that hospital and MRI and repeated CT-scans were performed several times and the hematoma in the upper vermis with a mass compression at the aqueduct is not resolving and progressing hydrocephalus taking place.

The patient was not to be known hypertensive, nor diabetic, and considering the localization of the lesion and the persistence of the mass, cavernous hemangioma was suspected and planned for direct surgery.

In the setting position, midline suboccipital approach with reflection of the bony flap down, the dura was opened v-shaped. Transvermian attack was performed and the cavernous hemangioma was resected easily and three tiny feeding arteries were identified and coagulated. The mass was extending to the forth ventricle, after removal of what, it was possible to see the posterior commissure and the widened aqueduct. The mass was sent for histological verification. Due to technical problems the video was recorded to a missing partition and the material was  with luck retrieved from the camcorder trash.

Comments:

1. Hypertensive encephalopathy with secondary bleeding can happen at any site in the brain, but there are certain areas were mostly common, the upper vermis is not among them.

2. When a mass with apoplexy persist for several weeks without gradual resolution, and more it has direct connection with ventricular system, but without evidence of slippage of the hematoma to the ventricular system, must hold suspicion with nature of the origin of bleeding. The cavernous hemangioma as in this case was sent for histological verification.

3. Instead of placing VPS, it is more wise to eliminate the cause of the hypertensive-hydrocephalic syndrome, if the procedure is surgically safe and effective.

The patient came 23-August-2006 with almost complete normalization of his neurological status, complaining of disturbed memory for recent events with control MRI showing normalization of the vermian area with some scattered old lacunar infarcts both periventricular localization, more in the left.

 

Pictures retrieved showing the transvermian approach and the upper and mid part of the 4th ventricle


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[2006] [CNS CLINIC - NEUROSURGERY - JORDAN]. All rights reserved