Surgical treatment of cerebral vascular pathologies in epiletic patients

SURGICAL TREATMENT OF PREMATURE SAGITTAL SYNOSTOSIS GERALDO PIANETTI* ABSTRACT - A series of 50 consecutive children with premature sagittal synostosis is reported. All were treated surgically; 43 were male, 47 were leukodermic and two are siblings. In the pre-operative examination, the head shape, skull measurements and radiologic findings were evaluated; 38 children were operated on before six months of age and 12 of them, between six and 12 months of age. The surgical technique used was a wide biparietal craniectomy. Blood transfusions were occasional, being necessary for only six (12%) children. The children were admitted at the day of surgery and discharged between the second and the third post-operative day. No local or general complications were observed and no one died. The aesthetic result was considered good. The altered skull measurements before surgery reached normalization as far as the end of the first year after the treatment. It may be concluded that wide biparietal craniectomy is a procedure of great effectiveness in the treatment of the premature fusion of the sagittal suture. KEY WORDS: craniosynostosis, sagittal suture. Tratamento cirúrgico da fusão prematura da sutura sagital RESUMO - É apresentada uma série de 50 crianças com fusão isolada e prematura da sutura sagital, tratadas cirurgicamente; 43 eram do sexo masculino, 47 leucodérmicas e duas irmãs. No pré-operatório foram avaliados o formato da cabeça, medidas do crânio e medidas radiológicas, 38 crianças foram operadas antes dos 6 meses de idade e 12 entre os 6 e 12 meses. A técnica cirúrgica usada foi a craniectomia parcial, ampla e biparietal. A transfusão sanguínea foi eventual, sendo necessária em somente 6 crianças (12%). As crianças foram admitidas no dia da cirurgia e receberam alta entre o segundo e terceiro dia após a cirurgia. Não foram observadas complicações locais ou gerais e não houve óbito. O resultado estético final foi considerado bom; as medidas do crânio, alteradas antes da cirurgia, se normalizaram até um ano após o tratamento. Conclui-se que a craniectomia parcial, ampla e biparietal é eficiente no tratamento da fusão isolada e prematura da sutura sagital, até o primeiro ano de vida. PALAVRAS-CHAVE: craniossinostose, sutura sagital. The first papers concerning the surgical treatment, of premature craniosynostosis were already published in the last century 17,18 . Nevertheless, as recently as the middle of the twentieth century, the surgical treatment of the premature fusion of the sagittal suture faced a strong resistance among 9 26 experts. Since Faber and Towne (1943) , Simmons and Peyton (1947) , Ingraham and cols. (1948) 14 many techniques have been proposed for the surgical correction of this malformation. It is already universally accepted that children having such a deformity should be treated early by surgical correction. T h e most used surgical techniques are the linear craniectomy w i t h placemení of interpositional material (polyethylene, silastic) 7,25 surgeons use wire to reduce the length of me s k u l l and the wide vertex c r a n i e c t o m y 1,15,30 4 2,22 . In children older than two years and having great skull deformity, a reconstruction of the vertex recommended, sometimes with bone transposition . Some or multiple cauterization of tiie diira mater or else the treatment of the dura mater with Zenker solution 13,19 8,11,12,21,28,29 27 or more invasive techniques are . Division of Neurosurgery, Hospital das Clínicas, Faculty of Medicine Federal University of Minas Gerais (UFMG), Hospital São Francisco de Assis, Belo Horizonte, Brazil: *M.D., M.S.C., Associate Professor. Aceite: 2-abril-1997. Dr. Geraldo Pianetti - Rua dos Aimorés 2480/902 - 30140-072 Belo Horizonte M G - Brasil. MATERIAL AND METHODS The children analysed here are part of an author's series of 104 patients with craniosynostosis. The children were operated on at the Division of Paediatric Neurosurgery of the Hospital São Francisco and Hospital das Clínicas in Belo Horizonte, Brazil, from January-1980 to December-1995. Fifty (48%) children presented a premature and isolated fusion of the sagittal suture. Forty-three children (86%) were male and seven (14%) were female. Forty-seven children (94%) were white and only three (6%) were black. Two were siblings. Among the other 48 there were no familial cases. Age at operation ranged from one to twelve months (average 6.3); 38 children (76%) were younger than six months of age. Clinical signs or symptoms of high intracranial pressure were not observed and only one child had another associated malformation (Pierre-Robin syndrome). Twenty-three (46%) were diagnosed at birth and, in one of them, premature fusion of the sagittal suture was observed before birth, through ultrasonography. Three children presented seizures; one had a familial history of epilepsy. On examination, the children always exhibited an abnormal shaped head which was scaphocephalic, sometimes with marked frontal bossing or/and an occipital bulge. Thirty-nine children (78%) had a palpable bony ridge along the sagittal suture and in 18 (36%) the anterior fontanel was oped at palpation. Ocular alterations were not observed. Six children presented a head circumference above the 98 percentile. The cephalic index ranged from 0.62 to 0.91 with the average of 0.81. In 42 children (84%) a cephalic index below normal was found, between 0.62 and 0.87 (average of 0.79). The other eight had a cephalic index of 0.89 on average. 6 In every child, the plain skull X-ray films confirmed the premature fusion of the sagittal suture and the scaphocephalic head shape. In a particular child more proeminent digitiform impressions were observed, in spite of no symptoms of intracranial hypertension. Thirty-six children (72%) underwent a CT scan. All of them were considered normal in relation to the brain, showed the scaphocephalic head shape and some of them showed a parasutural sclerosis on both sides of the ossified suture and an external or internal bony ridge along the suture. The pre-operative hematocrit ranged from 31% to 34%. Surgery was performed as early as possible following the neurosurgical diagnosis and the clinical-laboratory evaluation. Surgery consisted of a wide biparietal craniectomy that was carried across the coronary and lambdoid sutures. With the patient under general endotracheal anesthesia, a peripheral venous catheter was placed and a single dose of a broad-spectrum antibiotic was administered. It was important that the endotracheal tube would be fixed properly. The four limbs were wrapped in orthopedic cotton to keep the child warm. The child was placed in a prone position, with the head slightly extended and resting on a padded horseshoe headrest, leaving the vertex exposed from the frontal to the occipital region. Special care was taken to avoid pressure on the forehead and the eyes. Subcutaneous infiltration with epinephrine solution was used. (...truncated)