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Malignant tumours of jugular foramen are very rare in infants. To our knowledge there have been no earlier reports. The case of an infant who had a malignant schwannoma in the region of the jugular foramen is now reported. The difficulties of identifying a particular nerve as the origin of such a tumour are also indicated.
Herniation through the foramen of Winslow is a rare variety of paraduodenal hernia. We report a 19-month-old child with obstructive jaundice due to midgut herniation through the foramen of Winslow with associated volvulus. The herniation and volvulus were precipitated by intestinal malrotation. The patient underwent extraamniotic silo repair of exomphalos major in the neonatal period. Investigation for malrotation is recommended after extraamniotic closure of exomphalos.
The majority of congenital diaphragmatic hernias (CDH) occur through the foramen of Bochdalek; herniation through the foramen of Morgagni (MH) is rare. Fifteen children (12 males and 3 females) with congenital MH (7 right, 3 left, 5 bilateral) were treated over a period of 15 years, comprising 11% of a total of 135 children with different types of CDH. The majority (12, 80%) had repeated chest infections. In 1 the hernia was discovered accidentally during evaluation of trauma, and another presented in the neonatal period with acute respiratory distress (ARD). The diagnosis was made on plain lateral chest radiograph when there was anterior herniation of bowel loops, and in these cases the diagnosis was confirmed by barium enema. Computed tomography was useful in preoperative diagnosis when the hernia contents were solid. All patients were operated upon transabdominally except 1, and in all cases there was a hernia sac. Associated anomalies were present in 10 (66.7%) patients: 4 (26.7%) had malrotation, 4 (26.7%) congenital heart disease, and 3 (20%) Down's syndrome. Our study shows a relatively high frequency of MH in our patients. MH rarely presents in the neonatal period, but when it does, it causes ARD. The majority of patients with MH present beyond the neonatal period with repeated attacks of chest infection, and although late-presenting MH is relatively benign, it nevertheless causes significant morbidity. Thus, clinical awareness and early diagnosis and surgical treatment are important factors.
A 35-year-old man presented with pain in the right shoulder and neck for 18 months. The neurological examination revealed complete accessory nerve palsy on the right side without further deficits. Magnetic resonance imaging showed a right parapharyngeal tumour expanding into the posterior fossa through the jugular foramen without dural attachment and absence of invasion into the middle ear cavity or internal auditory meatus. Intraoperative inspection disclosed a tumour originating from the accessory nerve. Histological diagnosis revealed a meningothelial meningioma with invasion of the epineural space. To the knowledge of the authors this is the first report of an accessory nerve meningioma in the jugular foramen associated with a posterior fossa component and extension into the parapharyngeal space.
Two cases with huge dumbbell type jugular foramen meningioma with extension into the parapharyngeal space are reported. A well co-ordinated surgical strategy for total resection to this high risk tumour with neurosurgeons, otolaryngologists and plastic surgeons is mandatory to minimise operative complications. Both of our patients presented with a cervical mass and lower cranial nerve palsies, and had huge dumbbell type masses extending from the posterior cranial fossa through the jugular foramen to the parapharyngeal space, encasing the cervical internal carotid artery. Gross total resection of the tumours was successfully achieved by basically a 2-stage operation. In the first stage, posterior fossa tumours were removed by the transjugular approach, combined with the petrosal approach in one case. In the second stage, cervical tumours were removed along with the cervical carotid artery by the transcervical and/or transmandibular approach, followed by vascular reconstruction from the ipsilateral carotid artery to the middle cerebral artery using saphenous vein graft. From these experiences, we recommend this 2-stage operation for large dumbbell type meningiomas extending to the infratemporal/parapharyngeal space. The intracranial tumour is removed at the first operation. The extracranial portion is resected at the second, and if necessary, the involved cervical carotid artery is resected and simultaneous revascularisation using saphenous vein graft is performed with a vascularised free muscle graft. This strategy could maximise the functional preservation on the one hand, and minimise the surgical risk, such as postoperative infection, on the other.
We present here our experience of patent foramen ovale closure through a mini-invasive surgical technique. With the new surgical platform termed Heartport System, it is possible to install extra-corporeal circulation and to obtain cardioplegic arrest of the heart with endovascular techniques. This allows the operation of closure to be entirely performed through a micro-thoracotomy (Port-access surgery) in the right 4th intercostal space. Sixty-one patients underwent this surgical correction and seventeen of them (26%) had a diagnosis of patent foramen ovale, 12 with an history of cerebrovascular accidents. They are all alive and well after a mean follow-up of 16 months, with no recurrence of the inter-atrial communication and free from new neurological events. The post-operative course was uneventful with patients discharged on postoperative day 4. This technique shows a 100% efficacy, minimise surgical trauma, allows a quick recovery and offers excellent cosmetic results with no scarring. We believe that this procedure must be regarded as the "golden standard" for the closure of atrial septal defects
Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.
Observational studies have established a strong association between the presence of patent foramen ovale (PFO) and increased risk of ischemic stroke. The mechanism involved is presumed to be a paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation. The best treatment modality to prevent recurrent stroke in patients with PFO remains undefined. There are four major choices: 1) medical therapy with anticoagulants, 2) medical therapy with antiplatelet agents, 3) surgical closure, and 4) percutaneous device closure. The Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent neurologic events in stroke patients with a PFO. Medical therapy should remain as the initial choice of secondary prophylactic therapy. PFO closure, either surgical or percutaneous, may further reduce event rates; however, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.
Observational data from prospective and retrospective trials indicate that a patent foramen ovale (PFO) is associated with the risk of ischemic stroke. The mechanism involved is presumed to be paradoxical embolism from a venous thrombus that travels via the PFO to the systemic circulation causing an ischemic stroke. Primary stroke prevention data for patients with a PFO are nonexistent. Given the substantial prevalence of PFO in the total population (~ 25% to 30%), a primary prevention study may not be feasible. However, whether targeted primary prevention for patients with PFOs of certain morphologic characteristics (eg, larger size, greater degree of shunt) would be possible remains undefined. Given the large number of asymptomatic subjects, no therapy is currently recommended. The best treatment modality to prevent recurrent stroke in patients with PFO has not been defined. There are four major treatment choices: surgical closure, percutaneous device closure, medical therapy with anticoagulants, and medical therapy with antiplatelet agents. Regarding medical therapy, the Patent Foramen Ovale in Cryptogenic Stroke Study has demonstrated that antiplatelet and anticoagulant therapies are of equal benefit in preventing recurrent adverse events. Although closure of the PFO, either surgical or percutaneous, may further reduce the event rates, this remains to be demonstrated because no randomized trial to date has compared PFO closure with medical therapy.
Several uncontrolled studies suggested a relationship between patent foramen ovale (PFO) and stroke. But recent data indicate that previous studies may overestimate the association between PFO and stroke. First, among patients who have had a cryptogenic stroke under treatment (with either warfarin or aspirin), the main data from the French PFO/atrial septal aneurysm (ASA) and PICSS (Patent Foramen Ovale in Cryptogenic Stroke Study), analyzed separately and in combination, indicate that PFO alone does not announce a significantly increased risk of recurrent stroke or death. But a small increase or decrease in risk cannot be excluded by this meta-analysis. Second, the data concerning the association between PFO and ASA are not clear and variable: the French PFO/ASA study found a significantly increased risk of recurrent stroke in patients with cryptogenic stroke and an association between PFO and ASA when treated medically. In contrast, PICSS found no association between the combined PFO-ASA with stroke or death, but the two populations had meaningful differences. Patients in the PICSS were much older than those in the French PFO/ASA study and had more risk factors for stroke, such as hypertension, diabetes, and history of prior stroke. Third, there were inadequate data to conclude about ASA alone. Possible practice recommendations could come from this meta-analysis: the evidence indicates that the risk of recurrent stroke or death is not different for patients with a PFO who underwent cryptogenic stroke compared to patients without a PFO who underwent a cryptogenic stroke under treatment with either aspirin or warfarin. But aspirin is more preferable (300 mg/d). However, it seems that the association between PFO and ASA confers an increased risk of recurrent stroke in medically treated patients who are less than 55 years of age. This subgroup of younger stroke patients may benefit from other treatments, such as the percutaneous closure of PFO or mini-invasive surgery to a lesser extent, but their efficacy and safety are not yet assessed by large randomized trials. However, we must also keep in mind that some stroke patients with PFO are psychologically attached to their PFO and prefer to close it.
The valve of the foramen ovale of the heart changes at birth from a prenatal shunting device for the transseptal flow of systemic venous return to a postnatal active barrier to backflow of left atrial blood at higher pressure. To investigate the morphologic response to this functional change in the valve of the foramen ovale, we examined 200 hearts from embryos, fetuses and autopsy patients spanning over a millionfold range of heart weights (0.001 to 1,230 g). The relation of valve thickness to log heart weight was studied by a stepwise linear regression procedure that fitted the data to two linear regressions, one including observations made before birth and the other including observations made after birth. Analysis of variance tables demonstrated that the data are significantly better explained (p < 0.001) by two linear regressions that abruptly separate from one another at the time of birth than by a single linear regression. Histologic study showed that the prenatal valve consists of a thin myocardial layer with delicate endocardium. The postnatal thickening of the valve tissue occurs mainly by fibroelastotic thickening of the endocardium. The endocardial fibroelastosis of the valve develops after it closes and becomes a component of the left atrial wall. The observations support the concept that fibroelastosis is a nonspecific response of the lining of the cardiovascular system to increased mural tension.
In postpartum persistent right-to-left shunt at the atrial level, the valve of the foramen ovale fails to close. As a thin valve-flap the septum primum is pushed to the left during the phases of right atrial pressure predominance and closes to the septum secundum, when left atrial pressure exceeds right atrial pressure. Thus, it performs a marked movement during the cardiac cycle, reflecting the interatrial pressure-flow dynamics. With use of M-mode echocardiography, this movement pattern was studied in 24 patients: 13 with cyanotic heart disease (age 2 days to 21 years) and 11 newborns with persistent transatrial right-to-left shunt due to noncardiac disease. Cardiac defects were confirmed by cardiac catheterization and cineangiocardiography. Interatrial right-to-left shunts were proved by M-mode and 2-dimensional contrast echocardiography. The comparison of the M-mode echocardiographic findings in our patient groups with normal atrial septal movement studied in 20 healthy infants and children revealed considerable differences. The characteristic movement of the valve of the foramen ovale also was compared with results obtained by cineangiography and 2-dimensional echocardiography. Analysis of interatrial blood pressure difference provided a pathophysiologic explanation of the septum primum movement in transatrial right-to-left shunt.
A new approach for the management of the short-pedicled undescended testicle is presented. It was used in four patients with the testicle lying deep to the internal inguinal ring after all methods of cord elongation failed to bring the testicle down to the scrotum. The technique consists of passing the testicle through the obturator foramen to the scrotum. No complications were encountered, and the results have been satisfactory. Normally the vas deferens and testicular vessels describe a loop along their inguinal and pelvic course. The obturator foramen approach shunts this loop, which may be lacking in the undescended testicle lying deep to the internal inguinal ring.
We describe the case of a patient with deep venous thrombosis who had cerebral and extremity paradoxical emboli and an intracardiac thrombus crossing a patent foramen ovale identified by echocardiography. He was treated successfully with immediate intracardiac embolectomy and closure of the patent foramen ovale.
The authors describe a syndrome resulting from a lesion at the level of the infrapiriform foramen due to intramuscular injection, with involvement of the sciatic nerve, the inferior gluteal nerve, the posterior femoral cutaneous nerve and the pudendal nerve. This appears to be the first case of a complete syndrome of the infrapiriform foramen to be reported. In a second case the pudendal nerve was not involved and a releasing neurolysis was performed with remarkable postoperative relief. All the reported cases with involvement of the inferior gluteal nerve are associated with a more or less complete injury of the sciatic nerve. Conversely, the cases of injection injury to the superior gluteal nerve are rarely associated with injury of the sciatic nerve. The anatomic reasons that might explain both kinds of lesion are given. Finally some aspects of 131 cases of sciatic paralysis resulting from injection are also examined.
Locating the mental foramen in periapical radiographs is of great clinical importance. One thousand full-mouth intraoral radiographs were examined, and the location of the mental foramen in both the horizontal and the vertical planes was registered. In the horizontal plane 70 per cent of the mental foramina were found to be located between the two premolars, and 22 per cent were in the apical area of the premolars. In the vertical plane the highest percentage of mental foramina was found to be located superior to the level of the apices of the premolars.
Root canals of dogs' premolar teeth were exposed to contamination and to the development of periapical inflammation over a period of 45 days. Root canals were overinstrumented 2 mm beyond the apical foramen with file No. 60 and were underfilled by 2 to 3 mm short of the roentgenographic apex. Ninety days after endodontic treatment, healing and ingrowth of connective tissue into the root canal occurred in 67.8% of the cases. These results suggest that the diameter of the apical foramen and the intensity of the canal contamination are determining factors for periapical tissue repair in cases of pulpal necrosis.
The anteroposterior position of the mental foramen in eighty-seven southern (Hong Kong) Chinese skulls was compared with that reported for other ethnic and racial groups. The average position was essentially in line with the longitudinal axis of the second premolar tooth, a result similar to that reported for other Mongoloid populations, just posterior to the position in Caucasoids and anterior to the position in Negroids. These observations do not support the statement made in the majority of textbooks on dental analgesia that the foramen is most commonly found between the apices of the premolar teeth.