The Journal of Craniofacial Surgery
Brief Clinical Studies
In addition, Guyuron3 uses full-scale life-size photographs together with soft-tissue analysis to plan intraoperative maneuvers. A template is prepared together with the detailed numerical analysis of life-size photographs. With the help of the template, required surgical steps are planned and compared with the ideal aesthetic proportions. The technique described by Guyuron,3 without a doubt, brings many advantages to the surgeon. Guided by the ideal proportions and soft tissue cephalometric angles, the nasal bridge, nasal tip, contour, and the chin could be managed independently. However, most of these methods lack in documenting the instant intraoperative changes after certain rhinoplasty maneuvers. Surgeons commonly take the postoperative photographs of patient and compare them with the preoperative ones. Using this way, they try to evaluate the effects of their moves through comparison of the photographs. However, in the simple technique we described, surgeons can at least get a rough idea about the changes made during the surgery. The 3-point determination test can be repeated frequently during the operation. The key anatomic landmarks such as the radix, tip defining point, or alar bases can be compared with the original coordinates determined in the beginning of the procedure. In summary, with the method we demonstrated, surgeons can get an immediate data about intraoperative positions of the nasal aesthetic units. The technique is easy, cheap, fast, and readily available. Although it may not replace the more sophisticated analyses, we think that the ‘‘3-suture technique’’ might be a valuable adjunct to the aforementioned methods in rhinoplasty.
REFERENCES 1. Palma P, Khodaei I, Tasman AJ. A guide to the assessment and analysis of the rhinoplasty patient. Facial Plast Surg 2011;27:146Y159 2. Gunter JP. A graphic record of intraoperative maneuvers in rhinoplasty: the missing link for evaluating rhinoplasty results. Plast Reconstr Surg 1989;84:204Y212 3. Guyuron B. Precision rhinoplasty. Part I: the role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg 1988;81:489Y499
Reduction Cranioplasty for Macrocephaly Caused by Giant Occipital Cystic Lesion Nobuyuki Mitsukawa, MD,* Shoko Shimokawa, MD,Þ Atsuomi Saiga, MD,þ Kaneshige Satoh, MD* Abstract: Reduction cranioplasty for macrocephaly improves patients’ quality of life both functionally and aesthetically. However, it is indicated for only a small number of patients because of the risks From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba; and Departments of †Neurosurgery and ‡Plastic and Reconstructive Surgery, St Mary’s Hospital, Fukuoka, Japan. Received May 11, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Nobuyuki Mitsukawa, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, 260-8670 Japan; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000410
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& Volume 25, Number 1, January 2014
of complications. Thus, it is rarely performed, and not many reports have been published. In Dandy-Walker syndrome, there is often a posterior fossa cyst continuous with the fourth ventricle. We report here a case of scaphocephalic macrocephaly because of such a cystic lesion. The patient underwent a single-stage surgery with plication of the cyst wall and posterior reduction cranioplasty. This procedure achieved good results. Key Words: Reduction cranioplasty, macrocephaly, giant occipital cyst, Dandy-Walker syndrome
S
urgery for macrocephaly poses a risk for complications. Therefore, it is indicated for only a small number of patients. In addition, different patients have different problems that need to be resolved. The subject in this report had Dandy-Walker syndrome with a giant occipital cystic lesion, causing severe scaphocephalic macrocephaly. Thus, posterior reduction cranioplasty was performed, and good results were obtained.
CLINICAL REPORT The patient was a 5-year-old girl who was delivered by cesarean section with a birth weight of 3472 g. Since birth, she had cranium bifidum and a scaphocephalic deformity with a markedly long anteroposterior diameter of the head. Head computed tomography (CT) and magnetic resonance imaging (MRI) showed a cerebellar vermian defect, hydrocephalus, and giant occipital cystic lesion. Thus, the patient was diagnosed with Dandy-Walker syndrome. The patient had other congenital anomalies such as polydactyly, strabismus, and ptosis. When the patient was a few months old, neurosurgeons performed a radical surgery for cranium bifidum and placed a ventriculoperitoneal shunt for hydrocephalus. The developmental quotient was 8 at the age of 4 years, indicating a severe developmental delay. However, physical development was normal. The patient was unable to sleep in a supine position because of the severe scaphocephalic deformity and sometimes developed skin ulcers because of the weight of the head. Thus, she was referred to our department to improve these conditions. The initial examination revealed a severe dolichocephalic deformity with an anteroposterior diameter of 24 cm and a transverse diameter of 14 cm (Fig. 1A). Preoperative three-dimensional CT imaging revealed a scaphocephalic deformity with a tendency for premature fusion of the sagittal suture and coronal suture. Thinning of the bone was observed from the posterior fontanel to the lambdoid suture, and a bone defect was observed in 1 area (Fig. 1B). Preoperative MRI revealed a giant occipital cyst. There were multiple fibrous septal structures in the cyst, which appeared to have no continuity with the fourth ventricle. The cyst displaced and flattened the cerebellum and pons, and the corpus callosum was hypoplastic (Fig. 1C). Based on the above findings, the patient was diagnosed with severe scaphocephalic macrocephaly due to a giant occipital cystic lesion of Dandy-Walker syndrome. Because the brain parenchyma was distributed more toward the anterior, it was determined that reduction in cyst size would not have much effect on the brain parenchyma. Thus, posterior reduction cranioplasty was planned for functional and aesthetic improvement. Surgery was performed with the patient in a prone position and under general anesthesia. Circumferential osteotomy was performed in the protruded bone section in the occipital region, and the bone was removed. When the dura mater was incised over the cyst, a small amount of serous fluid was observed, but the cyst was mostly hollow. The cyst was isolated from the ventricles by fibrous septa. The fluid that had accumulated * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Brief Clinical Studies
rectangular pickets as bone flaps, the bone flaps were then bent and molded. The overlapping areas of the bone flaps were appropriately trimmed (Fig. 2B). The bone that was excised first was shaped properly and transplanted to repair the bone defect in the occipital region. Miniplate fixation was performed (Fig. 2C). The shrunken dura was tented in a few areas to prevent a dead space. The operative time was 480 minutes, and there was blood loss of 410 mL. The postoperative course was uneventful without major complications. Miniplates were removed at 1 year 6 months postoperatively. Currently, 2 years after surgery, the patient has achieved satisfactory bone fusion and marked morphological improvements. The anteroposterior diameter improved to 18 cm after surgery, and the patient was able to sleep in a supine position (Fig. 3A). Postoperative CT imaging revealed a decreased anteroposterior diameter of the head and decreased intracranial volume (2027 mL preoperatively to 1497 mL postoperatively) (Fig. 3B). Postoperative MRI revealed a giant cyst with reduced size and markedly improved cerebellum and corpus callosum (Fig. 3C). However, mental developmental delay seen preoperatively did not improve postoperatively.
FIGURE 1. A, Preoperative findings. B, Preoperative three-dimensional CT scans. C, Preoperative MRI scans.
was not cerebrospinal fluid (Fig. 2A). A portion of the cyst was resected, and the cyst wall was plicated to reduce the size. After osteotomies were performed in the surrounding bone to create
FIGURE 2. Intraoperative findings. A, The dura mater was incised over the cyst. B, Osteotomies were performed in the surrounding bone to create rectangular pickets as bone flaps in a so-called ‘‘picket-fence technique.’’ C, The bone pickets were then bent and molded. The resected bone was transplanted onto the bone defect in the occipital region, and miniplate fixation was performed.
FIGURE 3. A, Conditions at 2 years postoperatively. B, Three-dimensional CT scans at 2 years postoperatively. C, Magnetic resonance imaging scans at 1 year 6 months postoperatively.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e75
The Journal of Craniofacial Surgery
Brief Clinical Studies
DISCUSSION Surgery for macrocephaly poses a high risk for complications due to reduced intracranial volume and problems with the spinal fluid.1,2 The aim of the surgery is usually focused on improvement of quality of life, including aesthetic improvement. Therefore, such surgery is indicated for only a small number of patients and rarely performed. Most patients who are considered for reduction cranioplasty have developed hydrocephalic macrocephaly despite cerebral fluid shunting. Such cases have been reported previously.1Y10 In these cases, cerebrospinal fluid drainage was essential, and surgery was performed in 2 or more stages in many cases because of its risks. In recent years, Sundine et al8 have safely and effectively performed single-stage total cranial vault reduction on 4 patients with hydrocephalic macrocephaly. Kohan et al9 studied the outcomes of hydrocephalic macrocephalic cases in which patients underwent single-stage total cranial vault remodeling and postoperative helmet therapy. Gage et al10 reviewed all previously reported reduction cranioplasty cases and performed limited (posterior) reduction cranioplasty in 10 of their own patients with hydrocephalic macrocephaly. They minimized the invasiveness of the surgery and the duration of the hospital stay, and they were able to obtain optimal functional improvement. The patient of our report had Dandy-Walker syndrome with a giant occipital cystic lesion, causing severe scaphocephalic macrocephaly. Thus, posterior reduction cranioplasty was performed. Dandy-Walker syndrome is characterized by cerebellar vermian aplasia, posterior fossa cyst that communicates with the fourth ventricle, hydrocephalus, hypotonia, and mental developmental delay.11 Resection of the posterior fossa cyst is ineffective in 75% of the patients, and the mortality rate of resection is 10%.12 Our patient had brain parenchyma that was distributed more toward the anterior. The occipital cyst had septa and no continuity with the ventricles. Thus, cerebrospinal fluid drainage was not necessary, and surgery was performed relatively easily. Several methods have previously been reported on techniques for reduction cranioplasty in macrocephaly patients. The patient in our report underwent surgery only in the occipital region. There was a bone defect preoperatively in the center of the occipital region. Thus, strip osteotomies were performed in the surrounding bone to create rectangular pickets as bone flaps in a so-called ‘‘picket-fence technique.’’6,7 The patient was 5 years old. However, the older age of the patient did not pose a problem for reshaping, and bone fusion was satisfactory, and marked improvement was observed.
CONCLUSIONS Posterior reduction cranioplasty was performed in a patient with scaphocephalic macrocephaly due to a giant occipital cystic lesion of Dandy-Walker syndrome. The patient achieved marked morphological improvement after the treatment.
& Volume 25, Number 1, January 2014
6. Mansour N, Sobel L, Lee M, et al. A new method for the treatment of macrocephaly caused by hydrocephalus. Cleft Palate Craniofac J 2005;42:1Y6 7. Mathews MS, Loudon WG, Muhonen MG, et al. Vault reduction cranioplasty for extreme hydrocephalic macrocephaly. J Neurosurg 2007;107:332Y337 8. Sundine MJ, Wirth GA, Brenner KA, et al. Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly. J Craniofac Surg 2006;17:645Y655 9. Kohan E, Jackson E, Heller J, et al. Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy. Plast Reconstr Surg 2010;125:1763Y1770 10. Gage EA, Price AV, Swift DM, et al. Limited reduction cranioplasty for the treatment of hydrocephalic macrocephaly. Plast Reconstr Surg 2011;128:1272Y1280 11. Benda CE. The Dandy Walker syndrome or the so-called atresia of the foramen Magendie. J Neoropathol Exp Neurol 1954;13:14Y29 12. Hirsch J-F, Pierr-kakn A, Renier D, et al. The Dandy Walker malformation. A review of 40 cases. J Neurosurg 1984;61:515Y522
Vasculitis of Anti-Neutrophil Cytoplasmic Antibody After Liver Transplantation Hong Chen, MD, Tieyan Fan, MD, Xu Wang, MD, Jun Li, MD, Yujian Niu, MD, ZhongYang Shen, MD Objective: We reported a case of vasculitis of anti-neutrophil cytoplasmic antibody after liver transplantation. A 56-year-old male patient underwent orthotopic liver transplantation of the classic style on February 25, 2010 because of alcoholic cirrhosis. Methods: Pathology analysis showed it was nodular cirrhosis. The patient was given conventional treatment programs of FK (tacrolimus) + mycophenolate mofetil + hormone; hormone was suspended at the third month. He began to cough and spit, and there was blood in the sputum in September. Lung CT scanning images showed that there was a visible multiple low-density patchy shadow in both lungs; however, a number of other detecting results were negative. Results: Considering the patient with contact suspected mold, we improved the inspection and switched to experimental treatment (itraconazole), and the patient improved and was then discharged. Two months later, he complained about appearing hemoptysis. Final diagnostic results showed it was anti-neutrophil cytoplasmic antibodyassociated vasculitis after liver transplantation. Then we stopped medication with itraconazole. Treatment with methylprednisolone was continued, and the patient gradually stopped coughing and had no expectoration and hemoptysis.
REFERENCES 1. Parsons D, Samuels SI, Steinberg G, et al. Reduction cranioplasty and severe hypotension. Anesthesiology 1988;68:145Y146 2. Winston KR, Ogilvy CS, McGrail K. Reduction cranioplasty. Pediatr Neurosurg 1995;22:228Y234 3. Vries JK, Habal MB. Cranio-orbital correction for massive enlargement of the cranial vault. Plast Reconstr Surg 1979;63:466Y472 4. Erdin0ler P, Kaynar MY, Canbaz B, et al. Two different surgical techniques for reduction cranioplasty. Childs Nerv Syst 1998;14:372Y377 5. Takahashi Y, Tajima Y, Okura A, et al. Reduction cranioplasty for macrocephaly. Two case reports. Neurol Med Chir 1999;39:459Y462
e76
From the Institute of Organ Transplantation, Armed Police General Hospital, Beijing, China. Received June 15, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Dr ZhongYang Shen, Institute of Organ Transplantation, The Armed Police General Hospital, 69 Yongdin Road, Beijing 100039, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000418
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Brief Clinical Studies
In addition, Guyuron3 uses full-scale life-size photographs together with soft-tissue analysis to plan intraoperative maneuvers. A template is prepared together with the detailed numerical analysis of life-size photographs. With the help of the template, required surgical steps are planned and compared with the ideal aesthetic proportions. The technique described by Guyuron,3 without a doubt, brings many advantages to the surgeon. Guided by the ideal proportions and soft tissue cephalometric angles, the nasal bridge, nasal tip, contour, and the chin could be managed independently. However, most of these methods lack in documenting the instant intraoperative changes after certain rhinoplasty maneuvers. Surgeons commonly take the postoperative photographs of patient and compare them with the preoperative ones. Using this way, they try to evaluate the effects of their moves through comparison of the photographs. However, in the simple technique we described, surgeons can at least get a rough idea about the changes made during the surgery. The 3-point determination test can be repeated frequently during the operation. The key anatomic landmarks such as the radix, tip defining point, or alar bases can be compared with the original coordinates determined in the beginning of the procedure. In summary, with the method we demonstrated, surgeons can get an immediate data about intraoperative positions of the nasal aesthetic units. The technique is easy, cheap, fast, and readily available. Although it may not replace the more sophisticated analyses, we think that the ‘‘3-suture technique’’ might be a valuable adjunct to the aforementioned methods in rhinoplasty.
REFERENCES 1. Palma P, Khodaei I, Tasman AJ. A guide to the assessment and analysis of the rhinoplasty patient. Facial Plast Surg 2011;27:146Y159 2. Gunter JP. A graphic record of intraoperative maneuvers in rhinoplasty: the missing link for evaluating rhinoplasty results. Plast Reconstr Surg 1989;84:204Y212 3. Guyuron B. Precision rhinoplasty. Part I: the role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg 1988;81:489Y499
Reduction Cranioplasty for Macrocephaly Caused by Giant Occipital Cystic Lesion Nobuyuki Mitsukawa, MD,* Shoko Shimokawa, MD,Þ Atsuomi Saiga, MD,þ Kaneshige Satoh, MD* Abstract: Reduction cranioplasty for macrocephaly improves patients’ quality of life both functionally and aesthetically. However, it is indicated for only a small number of patients because of the risks From the *Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, Chiba; and Departments of †Neurosurgery and ‡Plastic and Reconstructive Surgery, St Mary’s Hospital, Fukuoka, Japan. Received May 11, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Nobuyuki Mitsukawa, MD, Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University, Faculty of Medicine, 1-8-1, Inohana, Chuo-ku, Chiba City, Chiba, 260-8670 Japan; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000410
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& Volume 25, Number 1, January 2014
of complications. Thus, it is rarely performed, and not many reports have been published. In Dandy-Walker syndrome, there is often a posterior fossa cyst continuous with the fourth ventricle. We report here a case of scaphocephalic macrocephaly because of such a cystic lesion. The patient underwent a single-stage surgery with plication of the cyst wall and posterior reduction cranioplasty. This procedure achieved good results. Key Words: Reduction cranioplasty, macrocephaly, giant occipital cyst, Dandy-Walker syndrome
S
urgery for macrocephaly poses a risk for complications. Therefore, it is indicated for only a small number of patients. In addition, different patients have different problems that need to be resolved. The subject in this report had Dandy-Walker syndrome with a giant occipital cystic lesion, causing severe scaphocephalic macrocephaly. Thus, posterior reduction cranioplasty was performed, and good results were obtained.
CLINICAL REPORT The patient was a 5-year-old girl who was delivered by cesarean section with a birth weight of 3472 g. Since birth, she had cranium bifidum and a scaphocephalic deformity with a markedly long anteroposterior diameter of the head. Head computed tomography (CT) and magnetic resonance imaging (MRI) showed a cerebellar vermian defect, hydrocephalus, and giant occipital cystic lesion. Thus, the patient was diagnosed with Dandy-Walker syndrome. The patient had other congenital anomalies such as polydactyly, strabismus, and ptosis. When the patient was a few months old, neurosurgeons performed a radical surgery for cranium bifidum and placed a ventriculoperitoneal shunt for hydrocephalus. The developmental quotient was 8 at the age of 4 years, indicating a severe developmental delay. However, physical development was normal. The patient was unable to sleep in a supine position because of the severe scaphocephalic deformity and sometimes developed skin ulcers because of the weight of the head. Thus, she was referred to our department to improve these conditions. The initial examination revealed a severe dolichocephalic deformity with an anteroposterior diameter of 24 cm and a transverse diameter of 14 cm (Fig. 1A). Preoperative three-dimensional CT imaging revealed a scaphocephalic deformity with a tendency for premature fusion of the sagittal suture and coronal suture. Thinning of the bone was observed from the posterior fontanel to the lambdoid suture, and a bone defect was observed in 1 area (Fig. 1B). Preoperative MRI revealed a giant occipital cyst. There were multiple fibrous septal structures in the cyst, which appeared to have no continuity with the fourth ventricle. The cyst displaced and flattened the cerebellum and pons, and the corpus callosum was hypoplastic (Fig. 1C). Based on the above findings, the patient was diagnosed with severe scaphocephalic macrocephaly due to a giant occipital cystic lesion of Dandy-Walker syndrome. Because the brain parenchyma was distributed more toward the anterior, it was determined that reduction in cyst size would not have much effect on the brain parenchyma. Thus, posterior reduction cranioplasty was planned for functional and aesthetic improvement. Surgery was performed with the patient in a prone position and under general anesthesia. Circumferential osteotomy was performed in the protruded bone section in the occipital region, and the bone was removed. When the dura mater was incised over the cyst, a small amount of serous fluid was observed, but the cyst was mostly hollow. The cyst was isolated from the ventricles by fibrous septa. The fluid that had accumulated * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 1, January 2014
Brief Clinical Studies
rectangular pickets as bone flaps, the bone flaps were then bent and molded. The overlapping areas of the bone flaps were appropriately trimmed (Fig. 2B). The bone that was excised first was shaped properly and transplanted to repair the bone defect in the occipital region. Miniplate fixation was performed (Fig. 2C). The shrunken dura was tented in a few areas to prevent a dead space. The operative time was 480 minutes, and there was blood loss of 410 mL. The postoperative course was uneventful without major complications. Miniplates were removed at 1 year 6 months postoperatively. Currently, 2 years after surgery, the patient has achieved satisfactory bone fusion and marked morphological improvements. The anteroposterior diameter improved to 18 cm after surgery, and the patient was able to sleep in a supine position (Fig. 3A). Postoperative CT imaging revealed a decreased anteroposterior diameter of the head and decreased intracranial volume (2027 mL preoperatively to 1497 mL postoperatively) (Fig. 3B). Postoperative MRI revealed a giant cyst with reduced size and markedly improved cerebellum and corpus callosum (Fig. 3C). However, mental developmental delay seen preoperatively did not improve postoperatively.
FIGURE 1. A, Preoperative findings. B, Preoperative three-dimensional CT scans. C, Preoperative MRI scans.
was not cerebrospinal fluid (Fig. 2A). A portion of the cyst was resected, and the cyst wall was plicated to reduce the size. After osteotomies were performed in the surrounding bone to create
FIGURE 2. Intraoperative findings. A, The dura mater was incised over the cyst. B, Osteotomies were performed in the surrounding bone to create rectangular pickets as bone flaps in a so-called ‘‘picket-fence technique.’’ C, The bone pickets were then bent and molded. The resected bone was transplanted onto the bone defect in the occipital region, and miniplate fixation was performed.
FIGURE 3. A, Conditions at 2 years postoperatively. B, Three-dimensional CT scans at 2 years postoperatively. C, Magnetic resonance imaging scans at 1 year 6 months postoperatively.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
e75
The Journal of Craniofacial Surgery
Brief Clinical Studies
DISCUSSION Surgery for macrocephaly poses a high risk for complications due to reduced intracranial volume and problems with the spinal fluid.1,2 The aim of the surgery is usually focused on improvement of quality of life, including aesthetic improvement. Therefore, such surgery is indicated for only a small number of patients and rarely performed. Most patients who are considered for reduction cranioplasty have developed hydrocephalic macrocephaly despite cerebral fluid shunting. Such cases have been reported previously.1Y10 In these cases, cerebrospinal fluid drainage was essential, and surgery was performed in 2 or more stages in many cases because of its risks. In recent years, Sundine et al8 have safely and effectively performed single-stage total cranial vault reduction on 4 patients with hydrocephalic macrocephaly. Kohan et al9 studied the outcomes of hydrocephalic macrocephalic cases in which patients underwent single-stage total cranial vault remodeling and postoperative helmet therapy. Gage et al10 reviewed all previously reported reduction cranioplasty cases and performed limited (posterior) reduction cranioplasty in 10 of their own patients with hydrocephalic macrocephaly. They minimized the invasiveness of the surgery and the duration of the hospital stay, and they were able to obtain optimal functional improvement. The patient of our report had Dandy-Walker syndrome with a giant occipital cystic lesion, causing severe scaphocephalic macrocephaly. Thus, posterior reduction cranioplasty was performed. Dandy-Walker syndrome is characterized by cerebellar vermian aplasia, posterior fossa cyst that communicates with the fourth ventricle, hydrocephalus, hypotonia, and mental developmental delay.11 Resection of the posterior fossa cyst is ineffective in 75% of the patients, and the mortality rate of resection is 10%.12 Our patient had brain parenchyma that was distributed more toward the anterior. The occipital cyst had septa and no continuity with the ventricles. Thus, cerebrospinal fluid drainage was not necessary, and surgery was performed relatively easily. Several methods have previously been reported on techniques for reduction cranioplasty in macrocephaly patients. The patient in our report underwent surgery only in the occipital region. There was a bone defect preoperatively in the center of the occipital region. Thus, strip osteotomies were performed in the surrounding bone to create rectangular pickets as bone flaps in a so-called ‘‘picket-fence technique.’’6,7 The patient was 5 years old. However, the older age of the patient did not pose a problem for reshaping, and bone fusion was satisfactory, and marked improvement was observed.
CONCLUSIONS Posterior reduction cranioplasty was performed in a patient with scaphocephalic macrocephaly due to a giant occipital cystic lesion of Dandy-Walker syndrome. The patient achieved marked morphological improvement after the treatment.
& Volume 25, Number 1, January 2014
6. Mansour N, Sobel L, Lee M, et al. A new method for the treatment of macrocephaly caused by hydrocephalus. Cleft Palate Craniofac J 2005;42:1Y6 7. Mathews MS, Loudon WG, Muhonen MG, et al. Vault reduction cranioplasty for extreme hydrocephalic macrocephaly. J Neurosurg 2007;107:332Y337 8. Sundine MJ, Wirth GA, Brenner KA, et al. Cranial vault reduction cranioplasty in children with hydrocephalic macrocephaly. J Craniofac Surg 2006;17:645Y655 9. Kohan E, Jackson E, Heller J, et al. Correction of hydrocephalic macrocephaly with total cranial vault remodeling and molding helmet therapy. Plast Reconstr Surg 2010;125:1763Y1770 10. Gage EA, Price AV, Swift DM, et al. Limited reduction cranioplasty for the treatment of hydrocephalic macrocephaly. Plast Reconstr Surg 2011;128:1272Y1280 11. Benda CE. The Dandy Walker syndrome or the so-called atresia of the foramen Magendie. J Neoropathol Exp Neurol 1954;13:14Y29 12. Hirsch J-F, Pierr-kakn A, Renier D, et al. The Dandy Walker malformation. A review of 40 cases. J Neurosurg 1984;61:515Y522
Vasculitis of Anti-Neutrophil Cytoplasmic Antibody After Liver Transplantation Hong Chen, MD, Tieyan Fan, MD, Xu Wang, MD, Jun Li, MD, Yujian Niu, MD, ZhongYang Shen, MD Objective: We reported a case of vasculitis of anti-neutrophil cytoplasmic antibody after liver transplantation. A 56-year-old male patient underwent orthotopic liver transplantation of the classic style on February 25, 2010 because of alcoholic cirrhosis. Methods: Pathology analysis showed it was nodular cirrhosis. The patient was given conventional treatment programs of FK (tacrolimus) + mycophenolate mofetil + hormone; hormone was suspended at the third month. He began to cough and spit, and there was blood in the sputum in September. Lung CT scanning images showed that there was a visible multiple low-density patchy shadow in both lungs; however, a number of other detecting results were negative. Results: Considering the patient with contact suspected mold, we improved the inspection and switched to experimental treatment (itraconazole), and the patient improved and was then discharged. Two months later, he complained about appearing hemoptysis. Final diagnostic results showed it was anti-neutrophil cytoplasmic antibodyassociated vasculitis after liver transplantation. Then we stopped medication with itraconazole. Treatment with methylprednisolone was continued, and the patient gradually stopped coughing and had no expectoration and hemoptysis.
REFERENCES 1. Parsons D, Samuels SI, Steinberg G, et al. Reduction cranioplasty and severe hypotension. Anesthesiology 1988;68:145Y146 2. Winston KR, Ogilvy CS, McGrail K. Reduction cranioplasty. Pediatr Neurosurg 1995;22:228Y234 3. Vries JK, Habal MB. Cranio-orbital correction for massive enlargement of the cranial vault. Plast Reconstr Surg 1979;63:466Y472 4. Erdin0ler P, Kaynar MY, Canbaz B, et al. Two different surgical techniques for reduction cranioplasty. Childs Nerv Syst 1998;14:372Y377 5. Takahashi Y, Tajima Y, Okura A, et al. Reduction cranioplasty for macrocephaly. Two case reports. Neurol Med Chir 1999;39:459Y462
e76
From the Institute of Organ Transplantation, Armed Police General Hospital, Beijing, China. Received June 15, 2013. Accepted for publication August 26, 2013. Address correspondence and reprint requests to Dr ZhongYang Shen, Institute of Organ Transplantation, The Armed Police General Hospital, 69 Yongdin Road, Beijing 100039, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000418
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
