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Laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 67-year-old woman with symptoms of partial colon obstruction is described. The patient had a prompt and complete recovery with no evidence of recurrence one year after surgery. The technique, which incorporates the rectus abdominal fascia in the repair, may be suitable for other laparoscopic surgical procedures.
A new case report of laparoscopic repair of a diaphragmatic hernia through the foramen of Morgagni in a 53-year-old woman is described. The patient had a successful recovery with no recurrence 2 years after surgery. The authors propose that the laparoscopic approach is an alternative to classical treatment for this kind of hernia.
A patient with a large pulmonary embolus is described. The striking features were those of cardiovascular stability with hypoxaemia and hypercapnia. Cardiac catheterization confirmed the pulmonary embolus; in addition there was found to be a patent foramen ovale (PFO), causing a large right-to-left shunt. Removal of the pulmonary embolus and closure of the PFO dramatically improved alveolar-arterial oxygen gradient and ventilatory requirements.
Patients undergoing major spinal surgery may experience significant postoperative pain. Epidural analgesia has previously been shown to be safe and effective and may confer some advantages over opioid-based postoperative analgesia. We discuss the case of a 47-yr-old female patient undergoing the prolonged anterior component of a lower thoracic/upper lumbar spine correction involving the stripping of the diaphragm from the lower thoracic spine and retraction of the left lower lobe of the lung. Despite initially planning opioid-based postoperative analgesia, a joint anaesthetic and surgical decision was made to use epidural analgesia in an attempt to avoid potential postoperative respiratory complications. Because of the surgical anatomy of the correction, the catheter was inserted via the T11 intervertebral foramen. A bolus of bupivacaine 0.25% intraoperatively with a postoperative infusion of bupivacaine 0.167% with diamorphine 0.1 mg ml(-1) provided excellent analgesia. The technique was associated with no postoperative complications.
AIMS: We report our experience with three generations of the Cardia patent foramen ovale (PFO) occluder in patients with cryptogenic thrombo-embolic events (TE). METHODS AND RESULTS: Between 1998 and 2004, interventional PFO closure was attempted in 403 patients. Prior to PFO closure, 605 TE occurred, translating into an annual incidence of 3.1%. PFO closure was successful in all patients. Peri-procedural complications occurred in eight patients (2.0%). At 6 months follow-up, residual shunt was present in 10.8% of patients. Transient thrombi developed on 10 devices (predominantly generation II) and asymptomatic wire fractures were detected in 14 cases (generation I and II). The annual incidence of recurrent TE was 2.0% (n=13). Atrial septal aneurysm and prior device-related thrombus formation were identified as predictors of recurrent TE. CONCLUSION: Owing to technical improvements and modified adjunctive pharmacotherapy, the rate of thrombus formation has declined and wire fractures are virtually absent in generation III devices. The overall rate of recurrent TE is reduced by transcatheter PFO closure with the Cardia PFO occluder, and seems comparable to recurrence rates reported for other devices used for this purpose.
We report on an adrenal carcinoma growing via the inferior vena cava into the right atrium and prolapsing into the right ventricle. A patent foramen ovale determined the pathophysiological and clinical appearance. Instead of an expected caval congestion the main features were paroxysmal dyspnoea and cyanosis. The patient was investigated using echocardiography, magnetic resonance tomography and angiography.
Disseminated granulomatosis is a well-documented complication of intravenous narcotism. We present here an interesting case in which this complication was caused by a right-to-left shunt (following intravenous injection of medicinal tablets intended for oral use) through a patent foramen ovale resulting from pulmonary hypertension due to angiothrombosis.
Bony defects (foramina) in the sternum were found in 6.7% of a large contemporary autopsy population. Usually solitary and located in the body of the sternum, these defects rarely occur multiply and in the manubrium. They have been found in children as young as 8 years as well as in persons of advanced age. Multiple mesosternal foramina and a manubrial foramen are described here for the first time. Sternal foramina form along lines of fusion of multiple centers of ossification and are the result of incomplete fusion. They have been misinterpreted as acquired lesions, usually gunshot wounds.
This study reports the intraoperative use of contrast and Doppler echocardiography techniques to diagnose patent foramen ovale (PFO). Fifty patients without known atrial septal defects undergoing elective cardiovascular surgery were studied. A 5-MHz esophageal echocardiographic probe was used to image the fossa ovalis (FO) and 10 ml agitated saline was injected into the right atrium during apnea. Echocardiographic contrast was then injected during end-inspiration at 20-cmH2O airway pressure. When opacification of the right atrium was complete, the airway pressure was released. During these maneuvers, color and pulsed-wave Doppler interrogation of the atrial septum were also performed. Right-to-left passage of saline contrast across the interatrial septum was seen in 11 of 50 patients (22%). Doppler echocardiography demonstrated a PFO in 2 patients without contrast evidence of shunting. Thus, the combination of contrast and Doppler echocardiography identified a 26% (13 of 50) prevalence of PFO, approximating the previously reported autopsy rate of 25%. These contrast and Doppler techniques may be useful in detecting patients at risk for paradoxical emboli and in identifying candidates for closure of the PFO.
BACKGROUND: Venous air embolism has been reported to occur in 23-45% of patients undergoing neurosurgical procedures in the sitting position. If venous air embolism occurs, a patent foramen ovale (PFO) is a risk factor for paradoxical air embolism and its sequelae. Preoperative screening for a PFO is therefore recommended by some investigators. The reference standard for identifying a PFO is contrast-enhanced transesophageal echocardiography (c-TEE). Contrast-enhanced transcranial Doppler ultrasonography (c-TCD) and contrast-enhanced transthoracic echocardiography (c-TTE) are noninvasive alternative methods, but so far there are no studies as to their diagnostic validity in neurosurgical patients. METHODS: The sensitivity and specificity of c-TCD and c-TTE in detecting a PFO were determined in a prospective study using c-TEE as the reference standard. Preoperative c-TCD, c-TTE, and c-TEE studies were performed during the Valsalva maneuver after intravenous echo-contrast medium (D-Galactose, Echovist-300, Schering AG, Berlin, Germany) was administered in 92 consecutive candidates (47 men and 45 women; mean age, 51 yr; range, 25-72 yr) before neurosurgical procedures in the sitting position. RESULTS: A PFO was detected in 24 of the 92 patients (26.0%) using c-TEE. c-TCD correctly identified 22 patients, whereas c-TTE only correctly identified 10. This corresponds to a sensitivity of 0.92 for c-TCD and 0.42 for c-TTE. The negative predictive value was 0.97 for c-TCD compared with 0.83 for c-TTE. The prevalence of a PFO in patients with a posterior fossa lesion was 27%, and in the group with cervical disc herniation was 24% as detected by c-TEE. The incidence of intraoperative venous air embolism was 35% in cases of cervical foraminotomy and 75% in posterior fossa surgery as detected by c-TEE. CONCLUSIONS: c-TCD is a highly sensitive and highly specific method for detecting a PFO. Because c-TCD is noninvasive, it may be more suitable than c-TEE for routine preoperative screening for a PFO. C-TTE is not reliable in detecting a PFO.
Foramen ovale electrode (FOE) implantation is usually indicated in patients with mesial temporal lobe (MTL) epilepsy. The authors conducted this study to characterize the electrical discharge patterns obtained using FOE recording and evaluated their clinical significance. Interictal and ictal discharge patterns and their temporal relationships to EEGs were examined in 16 patients who had FOEs implanted bilaterally and had good recovery from surgery. After long-term telemetry recording with FOEs, all patients displayed clear seizure onsets originating in one or both sides of the MTL and underwent an anterior temporal lobectomy. Interictal epileptiform discharges (IEDs) were lateralized to the operated side in 12 patients based on scalp EEGs and in 8 patients based on FOE recordings. Among the various possible IED patterns observed with the FOE recordings, a periodic pattern was dominant in the operated side (P = 0.001), whereas a polyspike pattern was dominant in the nonoperated side (P = 0.002). The number of patients with ictal onsets in the operated side was five based on the scalp EEG and 10 based on FOE recordings. Paroxysmal fast frequency activity, rhythmic spikes (>2 Hz), or sharp waves were dominant over other FOE seizure onset patterns in the operated side. By contrast, delta and theta slowing and positive spikes were prevalent in the nonoperated side. The start-stop-start pattern, previously described using subdural electrodes, was also found in FOE recordings and was concordant with the operated side in all cases. The interhemispheric propagation time recorded with bilateral FOEs was 22.6 +/- 20.0 seconds for ictal discharges initiated in the operated side and 7.0 +/- 8.4 seconds for those in the nonoperated side. Among various IED spreading patterns, the most prevalent progression was FOE --> contralateral FOE --> ipsilateral temporal lobe, or --> contralateral temporal lobe. In this series, FOE implantation caused no serious complications. FOE recording appears to be useful for confirming lateralization in patients with MTL epilepsy previously determined using clinical and neuroimaging methods. A thorough analysis of FOE recordings can provide information that may facilitate the differentiation of primary from secondary (nonepileptogenic) temporal lobes.
Six cases of a midline sternal foramen were found with CT. This anomaly occurred in 4.3% of patients who underwent CT of the thorax.
The incidence and characteristics of foramen thyroideum (FT) in embryonic and/or fetal larynges have not been established. In the present study, 90 adult larynges and 53 embryonic-fetal larynges were studied. The incidence of FT during the embryonic-fetal period (57%) was statistically different from the adult period (31%) (P = 0.005). All the FT found in the adult period contained vessels and/or nerves, while in the embryonic and fetal period only 63% presented neurovascular elements (P < 0.001). The origin of FT in the embryonic period and its persistence during adult life is discussed.
OBJECTIVE: The goals of this report were to outline the clinical presentation, radiological characteristics, surgical techniques, postoperative morbidity, and long-term follow-up results for cystic jugular foramen (JF) schwannomas and to describe their differences, compared with solid schwannomas involving the JF. METHODS: A retrospective analysis of radiological studies and surgical records identified five primarily cystic tumors among 21 cases of JF schwannomas that had been surgically treated at our institution. RESULTS: Two types of cystic JF schwannomas were observed, i.e., Type 1 lesions, which are single large cysts with thin ring-like enhancement of the tumor wall, and Type 2 lesions, which are multiple cysts with very irregular, thick enhancement of the cyst wall. The most common symptoms were hearing loss, ataxia, and headaches. Total surgical removal could be performed in all cases. The immediate postoperative findings indicated hearing improvement in three cases. No deterioration of lower cranial nerve function was observed. All patients were independent in the immediate postoperative period and in the long-term follow-up period (Karnofsky Performance Scale score, 90). CONCLUSION: Surgical treatment of cystic JF schwannomas can be very demanding because of generally stronger adhesion of the tumor capsule to the surrounding structures, fragile tumor capsules, and difficulty in identification of the arachnoidal planes in some cases. Early identification of the arachnoidal planes without opening of the cyst and sharp dissection may be useful. Careful intradural opening of the JF should be performed to achieve total removal of the last tumor portion within the JF. A comparison of these lesions with solid schwannomas involving the JF indicated that cystic tumors affected a younger population, with less preoperative swallowing impairment (P < 0.05). The immediate postoperative course in both types of cystic JF schwannomas was usually better than for solid lesions, because of minor postoperative cranial nerve morbidity, especially involving lower cranial nerve function, in the latter cases. Long-term follow-up data failed to demonstrate any significant differences in final patient outcomes, however.
OBJECTIVE AND IMPORTANCE: Patent foramen ovale (PFO) has been suggested as a potential source of paradoxical embolism. A higher prevalence of PFO in ischemic stroke of unexplained cause has been recognized. Brain abscesses are commonly associated with a contiguous focus of infection, hematogenous spread from a distant focus, or cranial trauma. However, no predisposing factors, including a distant focus with unknown cause, are identified in approximately 15 to 30% of reported cases. CLINICAL PRESENTATION: We encountered two patients with brain abscess presumably caused by dental infections. Both patients displayed PFO, through which right-to-left atrial contrast shunting was revealed by transesophageal echocardiography. Although the radiological location of the abscesses suggested hematogenous spread as a cause, the patients had no arteriovenous shunting other than the PFO, despite exhaustive investigations for a potential infectious route. The patients displayed no definite focal orofacial inflammatory signs during the postoperative course despite diagnosis of pyorrhea alveolaris or periodontitis. INTERVENTION: In Patient 1, the abscess was aspirated stereotactically, and in Patient 2, the abscess disappeared radiologically after high-dose antibiotic treatment. CONCLUSION: The mechanism of brain abscess formation putatively related to PFO should be different from that related to common dental sepsis. Analysis of these cases suggested that infectious embolism from a latent or even identifiable focus through the PFO may be an underrecognized cause of brain abscess, in contrast to simple seeding of the brain via transit of the infecting bacteria through the valveless emissary veins.
OBJECTIVE AND IMPORTANCE: Iatrogenic internal carotid artery-cavernous sinus fistula complicating percutaneous foramen ovale (FO) instrumentation (e.g., retrogasserian rhizotomy for trigeminal neuralgia) has been reported in only four patients to date. To our knowledge, no case of fistula has previously been reported either to complicate FO telemetry or to involve the inferior petrosal sinus (IPS); moreover, most patients have presented within 48 hours. We present a case of internal carotid artery-IPS fistula that complicated FO telemetry in which the clinical syndrome was delayed by 4 weeks. CLINICAL PRESENTATION: Four weeks after undergoing bilateral FO telemetry during Phase 2 investigations for surgery for epilepsy, a 37-year-old man suddenly developed a painful bilateral pupil-sparing oculomotor palsy, poor visual acuity, proptosis, conjunctival suffusion, and an audible bruit over the right frontotemporal region. INTERVENTION: Cerebral angiography demonstrated a high-flow arteriovenous fistula between the junction of the petrous and laceral portions of the right internal carotid artery and right IPS, with rapid filling of both cavernous sinuses. Successful obliteration was obtained with Guglielmi detachable coils, followed by complete resolution of the bilateral ocular abnormality. CONCLUSION: This is the first reported case of iatrogenic fistula formation to either involve the IPS or to complicate FO telemetry. In addition, symptomatology was anomalously delayed. This case highlights the importance of noting FO anatomic asymmetries before FO instrumentation and of routinely inquiring for "swooshing" noises after electrode withdrawal.
An asymptomatic 64-year-old black man presented with an enlarging left pleural mass. Preoperative evaluation failed to reveal an etiology. At thoractomy omental fat was found along the diaphragm, extending to the left costophrenic angle, and protruding through a hernia of Morgagni's foramen. The omentum was replaced into the abdomen and the defect was repaired.
The jugular foramen syndrome results from paralysis of various combinations of any of the last four cranial nerves. While trauma, vascular disease, and infection may be etiologic, most cases result from malignancies, usually metastatic. We have described a case of metastatic adenocarcinoma of the prostate resulting in the Collet-Sicard variant of this syndrome.