Journal of Research in Medical Sciences
Volume:18 Issue: 12, Dec 2013

Epilepsy surgery has been performed in western countries for over a hundred and fifty years. In Iran this operation in classic form started since 2007 in Kashani Hospital, Isfahan. This center has been approved by the ministry of health. Statistically about 1 percent of the population have epileptic seizure 20% of which are intractable and about half of this can be helped by operation. In Iran with the population of 7000000 there are about 75000 patients with intractable seizure can be helped by operation. We operated on 158 cases for past 6 years (from 2007-2013) 37.3 % female, 62.7 % male with the mean age being 25 years, 90% adult and 10% children, 76% in temporal region and 24% extra temporal. Type of pathology: mesial temporal sclerosis 39%, ganglioglioma 7.5%, Cavernoma 6%, astrocytoma 7.5%, DNET 4%, cortical dysplasia 10%, gliosis 11%, heterotopia 1%, others 6% and 6% of MTS were reported normal tissue. Type of operation: selective amygdalo hippocampectomy 48.5%, lesionectomy 47%, V.N.S. 2%, corpus callosotomy 2%. (33 months follow up) 88 % good result (ENGLES 1 and 2). Morbidity and mortality: no mortality, 2 patient transient Hemiparesis, 2 patients transient Hemianopia, 2 patients transient 3rd nerve paresis, 3 patients transient dysphasia, 2 patients depression and acute psychosis, 4 patient permanent hemiparesis.Conclsuion: Epilepsy surgery is a successful for treatment of resistance seizures.

In this study the protective effect of butylated hydroxyanisole (BHA)، a phenolic antioxidant used in foods، on Ferric-Nitrilotriacetate (Fe–NTA) induced nephrotoxicity is reported. Male albino rats of Wistar strain (4–6 weeks old) weighing 125–150 g were used in this study. Animals were given a single dose of Fe-NTA (9 mg/kg body weight،intraperitoneal) after a week of treatment with BHA (1 and 2 mg/animal/day). Fe-NTA treatment enhanced ornithine decarboxylase activity to 5. 3 fold، and [3H] thymidine incorporation in DNA to 2. 5 fold in kidney compared with the corresponding saline treated control whereas glutathione levels and the activities of antioxidant enzymes decreased to a range of 2–2. 5 fold in kidney. These changes were reversed significantly in animals receiving a pretreatment of BHA. The enhanced ornithine decarboxylase activity and DNA synthesis showed a reduction to 2. 12 fold and 1. 15 fold respectively at a higher dose of 2 mg BHA/day/animal، compared with the Fe-NTA treated groups. Pretreatment with BHA prior to Fe-NTA treatment increased glutathione and the activities of antioxidant enzymes to a range of 1. 5-2 folds in kidney. The results indicate that BHA is a potent chemopreventive agent and suppresses Fe-NTA induced nephrotoxicity in male wistar rats. However، a major concern which must be addressed when extrapolating animal findings to humans is the dosage of the agent studied.

One of the major complications resulting from head trauma is failure or dysfunction of vital body organs which has a remarkable effect on rate of mortality after brain injury due to trauma. This descriptive-analytical study was performed on all patients hospitalized in General ICU, NICU and Trauma Ward of Poursina Hospital with 8 ≥GCS). Patients were divided into two groups of dead and survived in terms of outcome. Then, the variables of age, sex, length of ICU stay, mean score of MODS (Multiple Organ Dysfunction Score), and mean GCS were analyzed using SPSS16 software and Logistic Regression analysis and Correlation analysis. This study showed that respiratory dysfunction was the most common complication after severe head trauma. It reached to 68% on the sixth day after admission. The incidence of renal failure during hospitalization was 4% with 75% death rate. The relationship between platelet counts with patient outcome based on three-month GOS was significant on the fifth and seventh days. The occurrence of liver dysfunction after severe trauma had a significant relationship with increased length of hospital stay and increased mortality. A strong correlation was found between non-neurologic organ dysfunction and patient’s outcome in severe brain injury. This study indicated the incidence of non-neurologic organ dysfunction in patients having severe brain trauma with increased adverse outcome and emphasizes the importance of early diagnosis and decisive measures to minimize the adverse impact of these outcomes in these patient.

Tourette’s syndrome is a psychiatric disorder characterized by motor, vocal tics, self-injurious problems and other psychiatric manifestations. We treated 3 cases of Tourette’s syndrome with a variety of motor and vocal tics and other psychiatric manifestation with Deep Brain Stimulation surgery. The ages of patients were 22, 24 and 25 years old. All of them had been diagnosed more than 10 years and refractory to all psychiatric management. The target was chosen in anteromedial of GPi (bilateral). The follow-up of these patients is 6-12 months and during this time all of the patients had a significant improvement of 80-95%. Although the number of our cases is too limited and no conclusion and be made based on that result, but we believe this result can help others to make the best decision of targeting for the management of Tourette’s syndrome.

Subarachnoid hemorrhage (SAH) is one of the cerebrovascular accidents which more common occurs in adults with age group of 35-65 years old. How to distinguish different measures which affect treatment, morbidity and mortality of patients with SAH is an important part of study. One of the aforementioned modalities is electrocardiogram (ECG) changes, which occur in most of involved patient. In this study we evaluated ECG changes in patients with SAH that admitted in three referral medical centers. In retrospective study with use of patients files with definite diagnosis of SAH in Kashani, Al-Zahra and Noor hospitals in Esfahan city, Iran, for 5 years sequentially, we studied 214 cases with SAH, evaluate of the ECC changes in these patients done by one cardiologist. Since these changes are like those occur in myocardial ischemia (MI) therefore the differential diagnosis of changes secondary to SAH from functional disturbances or true MI is very important. From 214 cases with SAH, 118 cases were women (55.1%) and 96 cases were men (44.9%), 30 cases had not any ECG on their files. 184 of cases had ECG on their files, which 117 of them had ECG changes (63.6%). Repolarization abnormalities were the most abundant changes observed (65.8%). Among above abnormalities, changes like myocardial ischemic which specifically related to ST segment and T wave changes were observed commonly.

Epilepsy surgery for lesions within or adjacent to the motor pathways (like insular tumors) could result to significant risk of a new motor deficit which presents one of the most disabling complications of such surgeries. So it is a major concern to neurosurgeons to delineate and monitor motor regions in order to preserve their structural and functional integrity, while still achieving maximal resection of tumor and epilepsy control. The technique of motor evoked potential recording has been available for clinical use now for almost ten years. In this article we report our clinical experience in 3 cases of intraoperative MEP and SEP monitoring in supratentorial tumors surgeries in and around the motor areas. In 2 of 3 cases MEP deterioration got reversed and in the third one no changes were found during monitoring. Our results show success of the MEP monitoring method in the prevention of a significant motor impairment. In one case we could resects the lesion totally and in two other cases the lesions resected near totally. Arm paresis (3/5) occurred immediately after surgery in one case. Intraoperative MEP recordings have been shown to reliably reflect an impending new motor deficit. Irreversible MEP deterioration heralds new paresis, and unaltered recordings predict preserved motor function. In conclusion, intraoperative MEP monitoring is a useful aid in brain surgery to avoid a new motor deficit without compromise to the surgical result. More controlled prospective studies will be required to verify the clinical value of this method.

Management of pineal region tumors has changed considerably during the past quarter century. Obtaining an adequate tissue sample for histological diagnosis is an important aspect of treatment planning. Open craniotomy can achieve this; however, the risk of permanent associated morbidity approaches 10%. Stereotactic biopsy sampling is a less invasive technique, but sampling error, due to the heterogeneous nature of tumors in the region, has been noted to be a significant problem. Stereotactic biopsy carry significant morbidity because of the numerous vascular structures in the vicinity of the pineal gland. Neither of this procedures however especially address hydrocephalus associated with mass in this area. This study is type of studies collection case-series and the Hospital Base. Eligible patients were examined at baseline and the final diagnosis was based on imaging methods. All of the patients with hydrocephalus were diagnosed with physical examination and imaging techniques Ventriculomegaly. Tumor markers such as alpha fetoprotein and human chorionic gonadotrophin beta of blood samples of patients captured. In case of negative markers patients undergoing surgery of neuroendoscopy were noted. Outcome of surgery include bleeding, infection, mortality, need for open surgery, and the need for shunt insertion in hydrocephalus patients symptoms before discharge were considered and included in the data collection forms were. After completion of the data in the study population, according to the purposes of data analysis was performed using software SPSS 17. In this study, 25 patients (10 women and 15 men) with tumors of the pineal with hydrocephalus, with a median age of 18 years and mean age 25 ± 19/3years (minimum 5 and maximum 65 years) undergoing surgery ventriculostomy using neuroendoscopy procedure (ETV) with biopsies were obtained.16 patients (64%) had no complications during and after ETV surgery did not show, 9 patients (36%), intraoperative and postoperative complications in patients follow up were different.In this study, mortality rate was zero. 12 patients (48%) of patients with germ cell tumors, gliomas, 10 patients (40%) and 3 patients(12%) had Ependymoma. Due to the lack of mortality in the patients and reduce the side effects during and after use of the surgical technique ETV, this technique can be a method of surgery safely in the pineal gland tumor combined by hydrocephalus.

Traumatic patients subject to post traumatic anosmia which its true diagnosis is so important especially in medicolegal issues. In this study we tend to evaluate the value of imaging findings in patients with post traumatic anosmia. In a cross-sectional study, 80 patients with complaint of anosmia due to trauma referring to East Azerbaijan''s legal medicine department from 2010 to 2012 and their anosmia was somewhat confirmed by olfactory tests and medical recording, were studied. Those patients meeting inclusion and exclusion criteria went under routine MRI, CT scan and ammoniac test and their findings were evaluated. Most patients (81.2%) were male. There were no significant differences between positive and negative ammoniac test in radiographic findings and CT scan findings such as fracture, hematoma, contusion and pneumocephalus. There was significant but not much powerful correlation between number of fractures in CT scan and neurologic findings with ammoniac test. In MRI in most cases hyper signal region in frontal lobe and then rectus gyrus was reported. In cases having hyper signal regions in frontal lobe, the most positive ammoniac test was seen. Results of this study showed that none of the modalities alone could diagnose post traumatic anosmia and for this purpose all available facilities such as olfactory tests, radiologic modalities and exact physical examination altogether should be utilized.

Spontaneous intracerebral hemorrhage (ICH) is a relatively common disastrous medical emergency causing a significant amount of mortality and morbidity. To this date, no precise guideline has been proposed to select the optimal medical strategy, either surgical or medical, for these cases. 1794 cases of spontaneous ICH where evaluated and 226 where included in this combined retrospective and prospective multi-centric analysis. The demographic and medical data in conjunction with 1-year follow-up GOS were meticulously analyzed and recorded. The patients were divided into medical and surgical groups based on the decision of the patient or his/her legal counterpart. After multivariate analysis age, history of diabetes mellitus and hypertension, volume of hemorrhage and GCS were recognized as the important prognostic factors and a scoring system was proposed according to these variables with a sensitivity of 86% and specificity of 73%. Using this system can be of further assistance in order to draw an objective decision for spontaneous ICH cases. Certainly, these criteria should be verified in our stage II trial (prospective study).

Spontaneous intracerebral hemorrhage (ICH) is a relatively common disastrous medical emergency causing a significant amount of mortality and morbidity. To this date, no precise guideline has been proposed to select the optimal medical strategy, either surgical or medical, for these cases. 1794 cases of spontaneous ICH where evaluated and 226 where included in this combined retrospective and prospective multi-centric analysis. The demographic and medical data in conjunction with 1-year follow-up GOS were meticulously analyzed and recorded. The patients were divided into medical and surgical groups based on the decision of the patient or his/her legal counterpart. After multivariate analysis age, history of diabetes mellitus and hypertension, volume of hemorrhage and GCS were recognized as the important prognostic factors and a scoring system was proposed according to these variables with a sensitivity of 86% and specificity of 73%. Using this system can be of further assistance in order to draw an objective decision for spontaneous ICH cases. Certainly, these criteria should be verified in our stage II trial (prospective study).

The purpose of this study is to evaluate the distribution, clinical features, and treatment modalities of arachnoid cyst in our department. The study was carried out between April 1, 2000 and October 1, 2009 at the Neurosurgery Department, Gheam Hospital Mashhad University. 20 patients with Arachnoid cyst underwent surgery between April 1, 2000 until October 1, 2009, consisting of 12 males and 8 females ranging in age 5 to 68 years (mean age 32.4 years). 12 patients underwent surgery and one patient underwent endoscopic fenestration, and cystoperitoneal shunting (medium pressure) was performed in 7 patients. All patients were followed for minimum of 6 months after surgery. During the study period, 20 patients were investigated. the cysts had strong predilection for the middle cranial fossa in 12 patients (60%), supra sellar region in 1 patient (5%), the cerebral convexity in 1 patient (5%), posterior cranial fossa in 2 patient (10 %), cerebellopontine angle in 3 patients (15%), quadrigeminal cisterns in 1 patient (5%). All of 20 cysts had clearly unilateral distribution, 12 (60 %) were located on the left side and 8 (40%) on the right side. The most common symptoms on presentation were epileptic seizures (46%), increased intracranial pressure (34%), visual impairment (5%), headache (10%), and cerebellar sign (5%). Arachnoid cysts have a strong predilection for the middle cranial fossa that may be explained by a meningeal maldevelopment theory, we also conclude that the major indication for surgery in patients with arachnoid cyst is the presence of intractable seizures, increased intracranial pressure, and compression of neuronal tissues. Headache only is not a surgical indication.

To determine the outcome of surgery for lumbar disc herniation and whether any difference is present between clinical results of four different surgical method and also to assess the effect of factors that could predict the outcome of surgery. We retrospectively evaluated 152 patients that were operated for lumbar disc herniation between March 2006- March 2011 with four different surgical techniques by using Japanese Orthopedic Association Back pain Evaluation Questionnaire (JOABPEQ), Return to activities of daily living scale, changes of visual analogue score for low back pain and radicular pain, and our study questionnaire that addressed patient satisfaction with the operation, residual complaints and job resumption.Four methods of surgery were laminectomy, spinous process osteotomy (muscle sparing technique), MAPN (microscopic assisted percutaneous neucleatomy) and unilateral laminatomy. 94% of our patients were satisfied with their surgery results. An overall 93.3% success rate with regard to Δ Visual analogue score (postop-preop) for radicular pain was achieved. Laminectomy resulted in better outcome in terms of JOABPEQ Low back pain functional score (p value 0.001), Lumbar function functional score (p value 0.002) and Walking ability functional score (p value 0.004). We had an overall rate 1.98% and 6% of recurrence and surgical complications respectively. 71.1% of cases complained of various residual symptoms. There was a significant statistical relation between age and three upper lumbar level disc herniation (P-value 0.001). When considering the effect of different factors on the outcome of surgery, no relation was found between outcome of different surgical techniques and age, gender, level of education, pre-op motor power, pre-op VAS for back, pre-op VAS for radicular pain, return to previous job (with an overall rate of 94% of patients going back to their job before surgery) and level of herniation. In this study Laminectomy achieved better outcome in comparison to other methods. From the results of our success rate with each of outcome measures, it is evident that surgery was mostly effective in reducing the radicular pain. It is also worth to mention that success rate with regard to patient overall satisfaction with the operation is almost equal to the success rate with radicular pain, which suggests that the most troublesome symptom for the patient was the radicular pain and its relief brought about satisfaction.

Thrombosis of the cerebral veins and sinuses is a distinct cerebrovascular disorder that, unlike arterial stroke, most often affects young adult and children. The symptoms and clinical course are highly variable. A teenager who has had recent headaches after starting oral contraception, a woman who has had seizures after delivery in the obstetrical ward, and a comatose man with a dilated pupil in the emergency room all may have sinus thrombosis. A prothrombotic risk factor or a direct cause is identified in about 85 percent of patients with sinus thrombosis. The most frequent but least specific symptom of sinus thrombosis is severe headache, which is present in more than 90 percent of adult patients. It usually increases gradually over a couple of days but can also start in a split second, mimicking a subarachnoid hemorrhage. In this case series study has paid attention to CVT patients who had sudden onset headache and because of their special brain CT scans was misdiagnosed as SAH at first. Its importance is in different management and treatment in these patients (treatment in one kills other patient). In the other hand manifestation of CVT may be as SAH in brain CT scan in witch treatment is completely different from other types of SAH. Cerebral lesions and neurologic signs develop in half of patients with sinus thrombosis. Characteristic, but rare, is the occurrence of unilateral hemispheric symptoms such as hemiparesis or aphasia, followed within days by symptoms from the other hemisphere; these are caused by the development of cortical lesions on both sides of the superior sagittal sinus. Anticoagulant therapy and its role in prevention from spreading of clot in the cerebral sinuses and veins is the key of importance in fast diagnosis and treatment and every misdiagnosis may lead to irrecoverable injuries for patients.

Shiraz is a main referral center for treatment of cerebra vascular lesions in southern Iran for more than 30 years. After development of subdivision in Shiraz neurosurgery group from 7 years ago, our experiences gradually increased and we are using multi modality treatment for cerebral arteriovenous malformation (AVM). Every year we are managing about 25-30 patients with AVM. The main presentations are hemorrhage, seizure and headache. About 50% manage surgically and the others by embolization and or gamma knife radio surgery. Young age is the most range and the majority presented with ICH. For patients with grade one, two and majority of grade three the main option is surgery. We are using preoperative embolization if needed. For high grade AVM embolization and then gamma knife are our options. We are using multi-modality treatment for management of cerebral AVMs in Shiraz.

We present our experience with corpus callosotomy (CC) in a developing country with limited resources in patients with Lennox-Gastaut syndrome (LGS) and medically refractory seizures. All patients with LGS who underwent CC for medically refractory epilepsy at Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran from May 2009 through March 2012 were reviewed in a retrospective study. Presurgical evaluation included clinical history, neurological examination, a 2-hour video-EEG recording, and 1.5-T MRI. Outcome was evaluated at 6, 12, and 24months postoperatively. We considered the outcome as a success if the patients were either seizure-free or had more than 85% reduction in seizure frequency compared to their preoperative status. Eighteen patients (14 males and 4 females) had surgery. Overall, seizures in 11 patients (61.1%) responded favorably one year after surgery; this figure was 6 out of 9 patients (66.6%) two years after surgery. Seven patients (38.8%) were free of disabling seizures one year after CC; this figure was three out of nine patients (33.3%) two years after CC. Three patients (16.6%) were free of all seizure types one year after surgery. Ten patients (55.5%) had no postoperative complications of any kind. Corpus callosotomy is an effective palliative surgical procedure for patients with LGS with intractable seizures whose seizures are not amenable to focal resection. This is a feasible treatment option for patients, even for those in developing countries with limited resources.

The aim of presenting this case is to evaluate the technical viability of unilateral approach to simultaneously clipping of bilateral aneurysm of MCA. 54 years old female presented with SAH grade IV, after treatment of vasospasm and good condition. Angiography revealed three aneurysms of right, left MCA and anterior commissure after 20 days of SAH and with GCS=15, unilateral approach was performed and clipped 3 aneurysm in one cession. Obliteration of contralateral aneurysm was possible. The patient didn’t show any complication. The unilateral approach to treat BMCA is a technically viable procedure, however it requires experience and cadaver dissections.

Neuroendocrine dysfunction following traumatic brain injury is frequently missed because of absence of major symptoms. Thus, no appropriate management is done and it may delay the patient recovery. This study is aimed to clarify the frequency and pattern of anterior pituitary dysfunction following TBI. Seventy patients, who were admitted to trauma center following TBI with GCS (Glasgow Coma Scale) of <12, were included. Patients were tested 6 months after injury for possible secretory abnormalities of anterior pituitary hormones. Basal level of target and pituitary trophic hormones were measured and dynamic test of stimulation with cosintropin and glucagons were done when needed. Forty one patients (58.6%) were suffered at least one hormonal secretory abnormality. The pattern and frequency of hormonal deficiencies were: gonadotropins (LH, FSH), 12.9%, ACTH, 12.9%, GH, 4.3%, and prolactin, 1.4%. There was no case with thyrotropin deficiency. Hyperprolactinemia was found to be present in 23 cases (31.5%). Gonadotropin and ACTH deficiencies are among the most common dysfunctions of anterior pituitary gland after traumatic brain injury.

Nobody nowadays is skeptic about superiority of endoscopic TSS over conventional one. Extended approach by going through tuberculum sella and planum sphenoidale may provide greater exposure for removing of retrochiasmatic craniopharyngioma and tuberculum sella meningioma and large superiorly extending adenoma pituitary adenoma. Since 2004 we have done pure endoscopic endonasal surgery, and in last three years we used those above mentioned technique in 44 huge and giant cases. In 17 patients extended approach and in 35 patients’ extracapsular dissection were performed. Due to high frequency of firm and previously surgical tried in this group it’s not surprising that in 8 giant cases both techniques were used. In all cases we were able to perform total resection and remove the subfrontal intraventricular and interpeduncular fossa extensions set aside cavernous sinus involvement. No patient experience worsening of vision or new neurological deficit. In 60 % of cases the pituitary gland was saved and at three month postop we observed acceptable adenohypophysis physiology. In five cases transient diabetes insipidus occurred. In one patient we have late post op CSF leak that with empirical antibiotic and bed rest her problem resolved Came out from sheer preeminence of endoscopy in endonasal approach are provided ability for extracapsular approach and extetended transplanum approach. Using these two technique surgeon can overcome giant and huge pituitary adenoma dilemma very safe and successful. Recruiting these strategy need for added transcranial approach and staged transsphenoidal surgery are approximately obviated.

There are different types of brain lesions that surgery might not be considered a good treatment option while adjuvant non-surgical treatments might be as effective in tumor control without any cyto-reductive intervention. Achieving a tumor tissue specimen is the main milestone in such cases. The aim of this study was to evaluate the usefulness and safety of stereotactic biopsy in histological diagnosis of such lesions. The data are extracted from a prospective project undertaken during a 15 year period in a single center. The inclusion criteria were all the patients referred by different clinicians interested in having histological diagnosis of their patients in hand. Thereby the authors did not exclude any of the referred cases from the list. The exclusion criteria were; local skin infection, coagulopathies and patients not accepting the mentioned risks of surgery in the consent sheath. There were 1000 patients all operated using BRW stereotaxic frame. There were 376 females (37.6%) and 624 male (62.4%) patients. The age range varied between 4 and 94 (mean = 47.3±18.07). The lesions were mainly located in the right cerebral hemisphere in 264, in the left hemisphere in 341, around the midline in 216 and involved both hemispheres in 166 cases. The lesions were diffuse or unidentifiable in 13 cases. There were a single lesions in 826 patients, two lesions in 11 cases and multiple in 162 patients. The main location of each lesion is presented in bar charts in the manuscript. The most common histological diagnoses were different grades of Astrocytoma in almost 600 cases followed by Lymphoma, metastatic lesions and infections. Eight cases became complicated because of intracerebra/intratumoral hemorrhage and brain edema. Frame based stereotactic biopsy can be a safe and useful armamentarium in the hands of neurosurgeons familiar with this type of procedure. The main indications and necessity for referring the cases for such a procedure will be discussed.

A variety of material and techniques have been introduced for endoscopic repair of idiopathic or traumatic CSF leak. With the evolution of endoscopic approaches and the expansion of their use to intradural lesions, their most demanding complication, post-operative CSF leak, should be addressed to let them survive. Use of pedicled local flap and the most common one, nasoseptal flap has evolved the reconstruction of skull base defects after these approaches. From June 2011 t0 July 2014, nasoseptal flap has been used for skull base reconstruction in 80 cases with various skull base pathologies including CSF leak from Sternberg canal, pituitary adenoma, craniopharyngioma and adenoid cystic carcinoma with intracranial extension in adults and children. Only 1 case of flap failure (due to technical problem) was encountered. Pros and cons of using the flap along with tips and tricks in the technique will be discussed on movies. Skull base reconstruction using nasoseptal flap is quite a reliable technique when dealing with high flow CSF leak in extended endoscopic endonasal approaches.

Gamma knife radiosurgery is a minimaly invasive procedure which can be used for patients with intractable epilepsies as an alternative for surgical corpus callosotomy there is no significant method for gamma knife callosotomy, our experiences in different way of callosotomy may be helpful. 24 patients with severe refractory generalized seizures associated with disabling drop attacks underwent GK callosotomy between 2006-2011.first 7 patients just anterior (1/3 ant) callosotomy and second 17 patients extended callosotomy up to near splenium. 35-40 Gy as thin as possible section was used as prescribing dose in all 24 patients and our mean follow up is 34m, in this period the frequency and severity of drop attacks and also generalized attacks were controlled several times. More than 63% decrease in drops in group1 and 75% in group 2 in this period is significant. The short period of follow and different types of medical therapy plus and different types of drug side effects make the conclusions difficult. Near total gamma knife callosotomy in short period has superior results in decreasing drops and generalized seizures. The severity and frequency of atonic and generalized epilepsy was significantly reduced in all patients and near total callosotomy is significantly better input follow.

Clivus chordomas (CC) is a form of primary bone cancer (malignant). They are rare disorders and their treatment is difficult. The purpose of this study was to evaluate outcomes after Endoscopic resection (ER) for these patients. Patients undergoing ER for CC were included and were retrospectively assessed based on outcomes. The demographic and clinical characteristics of patients including age, gender and complications rates were extracted from case records. Fourteen patients (7 females and 7 males) and the median age were 42.4 years (ranging from 14 to 66). The median follow-up time was 22.4 months (ranging from 3 to 31). Techniques typically such as CT scans or MRI, a blood test, or a biopsy was used to diagnose cancer. The most common presenting symptoms were diplopia, headache, dysphagia and dysarthria, and facial sensory changes. Gross total resection (n=10), and subtotal resection (n=4) was performed. The mean time to first recurrence was 19 months (range 10 to 22 months). Complication rates were as follows: meningitis7.1%, cerebrospinal fluid leakage 21.4%. No treatment-related neurologic deficit was observed. There was no mortality due to surgery. The ER for CC appears to be a safe and beneficial in patients. It seems, CC tumors can be resected with low mortality and morbidity

Traumatic brain injury (TBI) is a worldwide problem, especially in countries with high incidence of road traffic accident such as Iran. Patients with one single occurrence of TBI have been shown to be at increased risk to sustain future TBI. The aim of this study is to present the incidence and characteristics of repeated TBI in Kashan, Iran.

Spinal fixation surgery is potentially associated with significant bleeding, often requiring multiple blood transfusions. Concern for the risks of transfusion-acquired infection and immune modulation effects of allogeneic blood has led to the investigation of various hemostatic agents such as tranexamic acid (TXA). The investigators hypothesized that a prophylactic low dose of TXA would reduce blood loss and transfusion requirements during spinal fixation surgery. Of 92 patients, 76 were eligible for participation: 38 patients underwent TXA (10 mg/kg) at the initiation of induction of anesthesia during 10 min followed by intravenous infusion of 1 mg/kg/h (TXA group) and 38 patients received normal saline (control group). General anesthesia was administered and different hemodynamic parameters, complete blood count, abnormal prothrombin time, partial thromboplastin time, fibrinogen level, electrolytes, blood loss, and complications were assessed. Amount of blood transfused to the TXA group (n=10; 675±382 mL) compared with the control group (n=15; 600±220 mL) was not statistically significant (P=0.539). Total intraoperative blood loss was not significantly reduced in the TXA group compared with the control group (1269±690 vs. 1336±550 mL; P=0.659). In the 2 groups, fibrinogen level changed to the same extent and platelet count was reduced. Trend of changes in sodium, potassium, and calcium was the same in either group. No thromboembolic complications were clinically detected in either group. The administration of a prophylactic low dose of TXA did not have a significant effect in the management of intraoperative blood loss and transfusion requirements in patients undergoing spinal fixation surgery.

Object: This paper attempts to survey the prevalence of craniosynostosis phenotypes and age range at point of operation for each of them regarding the surgical method in patients who underwent two types of surgery methods including suturectomy and cranioplasty at a single major craniofacial surgery center in Iran. In a retrospective investigation, personal, clinical and paraclinical data were extracted from medical records of 250 operated infants/children with non-syndromic craniosynostosis. The surgical outcome difference between suturectomy and cranioplasty undergone population was compared. Prevalence of synostosis phenotypes was accounted; age range of subjects when operated was measured with attention to type of craniosynostosis and operation procedure. Schaphocephaly (40%) and anterior plagiocephaly (28.8%) were prevalently delineated among phenotypes respectively. The patients underwent surgery mostly aged 2-4 months (40.04%). Suturectomy (80%) and schaphocephaly (65%) were frequently appointed in this subcategory of age. Good recovery grade was apperceived in most of patients (92.8%). Overall, patients with oxcycephaly had not good recovery outcome. The type of operative method did not significantly effect on outcome. It was revealed that anterior plagiocephaly was most frequent in females, however; trigonocephaly and scaphocephaly were most common phenotypes in male ones. It seems that age at surgery is an important factor to prognosticate operative outcome in all phenotypes except oxycephaly. We claim that age at point of surgery is an extremely crucial criterion to achieve good recovery versus operative method. Accordingly, the reason of lost meaningful distinctive outcome between suturectomy and cranioplasty undergone subjects may be concealed on equality of age range in both operative methods.

Intra-cranial bleeding takes place in about 15% of patients with mild traumatic brain injury (mTBI). The risk factors for progression and expansion of hematoma and their natural course is not well known. This study was designed to elucidate the natural course, risk factors, and time interval for progression or regression of the post-mTBI intra-cranial hemorrhages (ICH). Eighty two patients with mTBI suffering intra-cranial hematoma on their initial brain CT scan were prospectively enrolled in a cohort study and data including accident characteristics, past medical history, and physical examination on their arrival were registered. They all underwent initial and repeat brain CT scans according to the protocol in our institute. Natural course of hematoma was demonstrated and data analysis of the patients’ characteristics and their CT scan findings was performed to elucidate risk factors associated with hematoma progression or the need for intervention. Age, sex, anti-coagulants, diabetes, associated trauma, type of the accident, transportation time, hemodynamic parameters, initial GCS, signs of skull base trauma, para-clinical measures, and primary size of hematoma were not associated with increased risk of hematoma progression (p>0.05). Sub-arachnoid and subdural hemorrhages resorbed after 6 days while epidural hematoma resorbed after 16 days from the accident. In this study, in accordance with previous studies, hematoma progression was preceded by clinical decline in all cases. It may be safe to discharge patients with normal sensorium after 24 h who do not show evidence of hematoma progression on repeat brain CT scan. However, further studies to externally validate these findings are warranted.

Lumbar disc herniation presents a common compliant with numerous procedure being carry out in patients with interactable pain or neurological deficits. Conventional lumbar microdiscectomy involves substantial excision of disc material form the intervertebral disc space to prevent herniation. However, in many cases recurrence disc herniation is unavoidable. Sequesterectomy in cases of herniated lumbar discs has been reported as an alternative to standard microdiscectomy. In this study the clinical records and the main questionnaires of 107 patients were analyzed and compared with literature. Preliminary results of a prospective randomized study in patients with lumbar disc herniation indicated equal recurrence disc rates and lesser reherniation in which patients are selected according to well defined criteria, which is largely depended on the competence of the annulus or posterior longitudinal ligament. There is tendency to superior clinical outcome in patients undergoing sequesterectomy. Microscopic sequesterectomy is more successful with lesser operating time with fewer intraoperative complications.

Traumatic spinal cord injury (SCI) constitutes a devastating event that often results in complete loss of motor and sensory function. Steroid hormones offer promising therapeutic perspectives during the acute phase of spinal cord injury while Progesterone and vitamin D remain controversial. The aim of the present study was to determine the effects of progesterone and vitamin D on outcome of patients with acute traumatic spinal cord injury. This was a prospective, randomized, double-blind, placebo controlled study being performed in Al-Zahra hand Kashani hospitals, both tertiary healthcare center affiliated with Isfahan University of Medical Sciences during a 1-year period from September 2012 to September 2013. We included those patients with acute traumatic spinal cord injury admitted to our center within 8 hours of injury. Those who had received methylprednisolone before admission, those on steroids, pregnant subjects, pure sensory loss and complete cord injury were excluded from the study. All the patients received methylprednisolone on admission according to standard protocol (30 mg/kg as bolus dose and 15 mg/kg each 3 hour up to 24 hours). Patients were then randomly assigned to receive intramuscular injection of 0.5 mg progesterone twice a day and 5mg oral vitamin D3 twice a day up to 5 days (n=32) or placebo (n=32). Patients were visited 24-hours, 6 days and 3 months after injury and motor and sensory function was assessed using International Standards for Neurological Classification of Spinal Cord Injury (ISCOS) and was compared between groups. There was no significant difference between two study groups regarding age (41.8 ± 13.6 vs. 45.1 ± 13.7; p=0.341), gender (p=0.802) and therapeutic approach (p=0.793). T12 (17.2%) and L1 (15.6%) were the most common involved segments. We did not found any significant difference between two study groups regarding the motor and sensory function of the involved segments after 24 hours, 6 days and 3 months. However the motor powers as well as sensory function increased significantly after 3 months in both study groups. The results of this study indicate that administration of progesterone and vitamin D in acute phase of spinal cord injury does not encompass neuroprotection effects. Further studies are required to shed light on this issue. Iran Clinical Trial Registry Code: IRCT201310082445N2

Traumatic subdural hygroma is the accumulation of cerebrospinal fluid (CSF) in subdural area after head trauma. The pressure of hygroma on brain can cause loss of consciousness in patient. There are still many obscurities on surgical indications of hygroma. This study focused on patients with traumatic subdural hygroma who underwent surgery within 11 years. In a descriptive (Case-Series) and retrospective study, records of 16 patients who had undergone surgery due to traumatic subdural hygroma were reviewed. ANOVA, Pearson and Spearman''s rho were used to analyze the data. In this study, there were 13 men and 3 women with mean age of 62 years. In 87% of cases, hygroma was diagnosed 6 days after head injury. In most cases (56.3%), it was observed in fronto-parietal area and in 81.3% of cases, it was in one side. The most common accompanying skull injuries were brain contusion (0.25%) and subarachnoid hemorrhage (18.8%). The changes in GCS on admission and discharge compared to time of hygroma had a significant difference (P<0.05). 25% of patients had hygroma recurrence after surgery. All patients (except one) had good outcome. The patient’s outcome was associated with the severity of primary head injury (P=0.003). No statistically significant relationship was seen between GCS on admission and GOS at hygroma time (P>0.05). Subdural hygroma is a delayed complication and surgery treatment improves the consciousness state of patients with this problem.

Most patients with brain abscess, will present with signs and symptoms of space occupying lesion, such as headache. They may also present with focal neurological deficits and seizure the aim of this study is determination of focal neurologic sign and seizure 102 patents in Kashani and AL-Zahra hospitals in Isfahan for five years. In a retrospective study with use of patients’ files with definite diagnosis of brain abscess, we evaluate sex, age focal neurological signs and seizure in 102 patients in Kashani and Al-Zahra hospital in Isfahan, Iran for five years sequentially. Male was 69.6 percent and remainder were female the age of first decade was more than other age groups, focal neurologic signs include headache (68/5%) hemiparesis (44%) and seizure (36%) were more than the other signs. Infection of ears and sinuses were (23.5%), trauma was 16.5%, staph was more than other organism (14.5%) among risk factors, congenital heart disease was the predominant cause (15.5%) For differential diagnosis of focal neurological sign and seizure when a patients present with these symptoms brain abscess most be in mind.

The most important complication of head trauma is acute subdural hemorrhage (ASDH). This is emergency of neurology that diagnosis and treatment in the earlier stage is effective in improve the prognosis. Aim of this study is evaluate the frequency of neurologic signs level of consciousness and seizure in ASDH. In a retrospective study and cross sectional samples of 400 patients with ASDH in the Kashani and Al-Zahra hospitals in Isfahan, Iran for four years we evaluate the frequency of neurologic sign, level of consciousness and seizure. The male female ratio was 4.8/1, the most rate of age was 61-70 year, trauma was most common etiology of ASDH (98.5%), the frequency of neurologic signs were: Facial paralysis (4.5%) motor sign (15%), urinary incontinence (6%) change in level of consciousness (49.75%) the frequency of seizure was 9%. Since the most presentation of A.SHD is decrease level of consciousness determine the level of consciousness intermittently in patients with ASDH is very important.

Traumatic brain injury is one of the most common causes of mortality and morbidity among the young and middle aged. This study was conducted to evaluate the factors that affect the outcome of the patients with moderate to severe traumatic brain injury. This descriptive analysis study enrolled 460 patients with moderate to severe traumatic brain injury, according to Glasgow Coma Scale (GCS) score, who were admitted in Shahid Bahonar Hospital of city of Kerman during one year (October 2009 to October 2010). Data collection tool was a checklist that includes level of conciseness, age, gender, type of trauma, level of arterial oxygen and arterial blood pressure. Level of conciseness was evaluated according to GCS score at the time of admission at emergency room and six and 12 hour after that. Age of patients was 10 ± 28.3 years (mean ± SD). Duration of admission was 15.4 ± 8.3 (mean ± SD) that had significant relationship with GOS (P= 0.0001). Sixty percents of patients had good outcome. GCS at the time of admission and 6 and 12 hour after that had significant relationship with GOS (P=0.005) but logistic regression analysis showed that only GCS of patients 12 hour after arrival had significant relationship with GOS (P=0.004). GCS of the patients 12 hour after arrival is the most important prognostic factor in traumatic brain injury so data about GCS should be recorded meticulously to assess the outcome.

Chordomas are locally invasive tumors that have a tendency to relapse despite optimal treatment. Specific biological markers might be used to describe their behavior. There is currently no agreement regarding the best way to manage intracranial chordomas. We studied the expression of vascular endothelial growth factor receptor 2 (VEGFR-2), inducible nitric oxide synthase (iNOS), and Ki-M1P in 145 paraffin-embedded tumors. The purpose of our study was to determine: (a) the role of potent angiogenic factors VEGFR-2 and iNOS and their relationship to each other in skull base chordoma and (b) the role of monocytes/macrophages as a potential iNOS source in the angiogenic process. A series of 74 chordoma patients for a total of 145 lesions (including 71 recurrent lesions) and 10 specimens from embryonic notochord were investigated for the expression of iNOS, VEGFR-2, Ki-M1P, and CD-34 using immunohistochemistry. In the majority of the chordomas, correlations were found between iNOS and the immunoreactivity of Ki-M1P (r = 0.5303, P < 0.0001). Furthermore, the expressions of Ki-M1P was correlated with VEGFR-2 (r = 0.4181, P < 0.0001). Our results indicate that chordomas may respond to receptor tyrosine kinase inhibitors such as VEGFR-2 or modulators of other downstream signaling molecules. The future of VEGFR-2 and iNOS inhibitors as therapeutic agents in the treatment of chordoma will be clearer over the next years as results of the current clinical trials become available and as the factors regulating angiogenesis and the interactions between these factors are elucidated. However, appropriate functional experiments remain to be conducted to prove such a hypothesis.

The aim of this study was to assess the outcome of inter-spinous device (ISD) implantation for 85 patients who had been operated microsurgically for disc herniation and multi-level canal stenosis. 85 patient s who has been suffering from leg pain, back pain and claudication divided to three groups, 34 patients in group A were operated for pure disc herniation; patients in group B under went operation for disc herniation and multi-level canal stenosis they were 27 patients and 24 patients in group c operated for pure canal stenosis, approach of operation was unilateral microsurgical discectomy and ISD implantation (DIAM or UNIWALLIS) for pure disc herniation, unilateral or bilateral microsurgical discectomy and foraminotomy and ISD implantation for disc herniation and canal stenosis patients we did only bilateral fenestration plus foraminotomy and ISD implantation for the pure canal stenosis patients, visual-analogue scale (VAS) score and ODI score assessing performed for all three group patients preoperative 4 weeks post-operative 6months and one year post-operative The mean VAS score at 12 months postoperatively decreased by 39.0%. Oswestry score was 31% preoperatively, 24.7% at 6 weeks, and 20.3% at 12 months postoperatively on average. In 5 of the implanted 85 patients, the UNIWALLIS or DIAM had to be removed and reoperation had to be performed because of disc recurrence. Our center results indicate not only a satisfactory short-term, but also a good long-term effect during a follow-up period of one year.

Posterolateral approaches have been used to successfully perform corpectomies for traumatic fractures. This study aims to assess the outcome of posterolateral single stage corpectomy and posterior fixation in patients with spine traumatic vertebral fracture. This was a case series including 8 patients with traumatic vertebral fractures referring to our center in Gottingen University from October 2011 to September 2013. All the patients had traumatic vertebral fracture and incomplete cord damage. All the patients underwent corpectomy through posterolateral approach and anterior cage insertion was performed along with posterior pedicular screw fixation. Patients were followed after the operation for 12 months and the standard neurological classification of spinal cord injury (ASIA) score was assessed for each patient. Overall we included 8 patients who underwent the procedure. All the patient had an uneventful operation and postoperative period. Mean ASIA score increased significantly after 12 months follow up. None of the patients developed complication during the follow-up period. Single stage corpectomy and posterior fixation approach can be beneficial for incomplete traumatic burst fractures.

Pain management after lumbar discectomy is controversial. Although several pharmaceutical agents have been used for management of postoperative pain (POP), nausea and vomiting (PONV) after lumbar discectomy undergoing spinal anesthesia; however this issue remains elusive. The aim of the present study was to investigate the effects of intrathecal administration of bupivacaine (Marcaine) in addition to morphine, neostigmine or Fentanyl in management of POP and PONV after lumbar discectomy. This was a randomized, double blind clinical trial being performed in Al-Zahra healthcare center affiliated with Isfahan University of Medical Sciences during a 1-year period from September 2012 to September 2013. We included those 116 patients with single lumbar disc herniation without neurological deficit undergoing discectomy. We excluded those with previous lumbar surgery and those in whom the dural sac was opened. Patients were randomly assigned to receive intrathecal administration of 15 mg bupivacaine in addition to 0.2 mg of morphine (n=47) or 50-150 µg of neostigmine (n=33) or 25 µg of fentanyl (n=36). The pain scores according to numeral pain scale (NPS) and well as incidence of PONV were recorded and compared between groups. The baseline characteristics were comparable between groups. The pain intensity after the operation was comparable between groups after 2 (p=0.187) and 4 (p=0.682) hours. However those who received bupivacaine and Fentanyl had significantly lower NPS scores after 6 (p=0.029), 12 (p=0.049) and 18 (p=0.013) hours. The incidence of PONV (p=0.269) and urinary retention (p=0.986) as well as amount of administered analgesics (p=0.128) was comparable between three study groups. The results of the current study demonstrates that intrathecal administration of bupivacaine and fentanyl in those undergoing single lumbar discectomy via spinal anesthesia is associated with lower postoperative pain intensity.

Spinal dysraphism is a general term used to identify developmental spinal cord abnormalities. The most common form is known as spina bifida or “split spine.” Each year, one in a thousand babies are born with spina bifida (meningomyelocele), a malformation of the bones (vertebrae) and/or skin surrounding the spine that can lead to serious infections, problems with bladder and bowel function, hydrocephalus, and paralysis. In most cases, surgical correction of the neural tube defect can prevent such complications. This study aimed at evaluating the patients hospitalized in Imam Reza Hospital of Tabriz from 2000 to 2012. The patients with spinal dysraphism admitted and operated between the years 2000-2012 in Imam Reza Hospital of Tabriz were studied during a 9-month period. The type and location of spinal dysraphism, dermal, neurological and skeletal findings, results of surgery and complications were determined. The manifestations and complications were compared the aperta and occulta. 59 patients (33 males and 29 females) with the mean age of 1.2±4.8 years were enrolled in this study. There were 48 aperta and 11 occulta types. The most commonly involved location was lumbosacral region. The most frequent dermal, neurological and skeletal findings and operation-related complications were a sac over the back (78%), lower limb weakness (61%), scoliosis (37.7%) and hydrocephalus aggravation (18.6%), respectively. Postoperative improvements of motor weakness and sphincteric dysfunction were seen in 47.2% and 80% of the cases respectively. There were no significant differences between the two groups of aperta and occulta spinal dysraphism regarding the manifestations and complications (p>0.05) The aperta spina bifida is the most common type of spinal dysraphism and aggravation of hydrocephalus is the most common complication.

It is demonstrated that tethered cord syndrome is not necessarily identical to low lying conus medullaris and a separate entity of this syndrome with normally placed conus medullaris is also well recognized. Besides, normal clinical history and neurological exam does not preclude the diagnosis of this syndrome either. Subclinical changes in bladder function have also been described as an insidious sign of this problem. Recognition of the aforementioned types of tethered cord syndrome seems to be vital in patients who are candidate for correction of congenital scoliosis. Through this study, 1000 patients candidate for surgical correction of congenital scoliosis are assessed with whole CNS MRI, urodynamic study, and CT myelography in a single center. The cases without any obvious clinical signs and symptoms of tethered cord syndrome and normal MRI and CT myelography but with abnormal urodynamic parameters indicating neurogenic bladder are selected. These cases undergo surgery and the filum terminale is cut. The surgical findings are recorded and the postoperative status is then evaluated by a follow-up MRI and urodynamic study performed three months after the surgery. The possible improvements in urinary status then will be recorded and meticulously analyzed. Among the first 250 cases of scoliosis, 32 had abnormal urodynamic studies and normal clinical and radiological assessments. In seven, fatty changes were seen in the filum terminale and among the others tight filum terminale was discovered in 18 patients. Significant improvement in urinary status was also evident in 21 cases (65%). Rise of the conus medullaris in MRI was seen in only one case during the follow-up. It seems that clinical examination and MRI are not enough to rule out tethered cord in congenital scoliosis. Further evaluation with urodynamic study is essential to identify some subclinical urinary problems or to recognize the normally placed conus medullaris variant before corrective surgery of this deformity.

Intracranial arteriovenous malformations (AVMs) are congenital vascular lesions affecting 0.01-0.5% of the general population. Radiosurgical treatment has a slow and progressive thrombotic effect on fragile vessels of AVMs. The aim of this study was to evaluate the long-term clinical and the radiological outcome of the patients on treated AVMs with Leksell Gamma knife radiosurgery. We reviewed the outcomes of 388 patients who underwent Gamma Knife radiosurgery for AVMs in 8 years starting from 2002. These results are compared to other contemporary radiosurgical series. Patient follow up was performed by MRI, MR angiography or Angiography. The patients were followed up for a mean period of 61.6 months (range, 12 to 93 months) after the initial GKS. 95% of patients with AVMs had follow-up imaging. Complete obliteration in angiographic studies was observed in 45% of the patients in the first year of follow up and 64% in mean 5 years follow up and also reduction in lesion volume was noted in MRI studies in 65% of cases after mean 5 years. A significant relation was found between obliteration rate and risk of hemorrhage (p<0.001). Complications such as transient hemi-paresis, VA and VF defect, cranial nerves palsy and very low rate of re-bleeding mostly in first year & in subtotal obliteration was observed. GKS for cerebral AVM offers an effective and relatively safe treatment modalities, with low complication rate. AVMs are well-suited for radiosurgery, since radiation can be focused on a well circumscribed region, while adjacent neural structures are spared. Cortically located AVMs with a nidus volume less than 10 ml could be operated, with or without pre-surgical embolization, unless there is a single feeder that can easily be catheterized and embellished for obliteration, or other obvious target for embolization such as pseudoaneurysms or large fistulae. Centrally located AVMs with a nidus volume less than 10 ml should be treated by radiosurgery, unless suitable for embolization as indicated above.

This study compared Gamma knife radiosurgery (GKRS) and repeated transsphenoidal adenomectomy (TSA) to find the best approach for recurrence of Cushing disease (CD) after unsuccessful first TSA. Fifty-two patients with relapse of CD after TSA were enrolled and randomly underwent a second surgery or GKRS as the next therapeutic approach. They were followed for a mean period of 3.05 ± 0.8 years by physical examination and hormone measurement as well as magnetic resonance imaging. No significant difference was observed in sex ratio, mean age, adenoma type, follow-up duration, and initial hormone level between the two groups. No significant relationship was found between preoperative 24-hour free urine cortisol and disease-free months or tumor volume among both groups. Our statistical analysis showed higher recurrence-free interval in the GKRS group compared with TSA group. With longer recurrence-free interval, GKRS could be considered a good treatment alternative to repeated TSA in recurrent CD.

Meningioma of the spinal cord most often occur in middle aged women. Meningiomas of the spine arise from arachnoid cap cells that is embedded in the dura of the nerve root. Despite usually being small, due to the confines of the spinal canal they can result in significant neurologic dysfunction. The majority of patients present with motor deficits as a result of compression of the spinal cord. Less common presentations include sensory deficits, pain and sphincter dysfunction. In our case series study between 2002 and 2012 in the university hospitals we had 20 patient with the sign of flexing hip and knees (squatting posture) in lying position. Female to male ratio was 4/1. The main presentation of them was difficulty in walking but three of them had contractures and urinary symptoms such as urgency and in one of them with incontinencies. All of them were posteriorly placed tumor and underwent operation with laminectomy, aimed at tumor that successfully extirpated. In 17 patients spasticity returned to normal with normal gait with mild weakness and in 3 of them with contracture that had not good recovery in follow-ups. Painful spasticity were not disabling, and gait was walker dependent. No one of them had recurrent tumor after two years follow-up. Our recommendation is that beside common signs of spinal meningiomas we should consider the “Squatting Posture” as a sign that can lead to suspecting us to the Spinal Meningiomas.

Traumatic brain injury is a major cause of mortality and morbidity in pediatric age group. ICP monitoring and early decompressive craniectomy in cases that develop intracranial hypertension has been described to be the method of choice in many pediatric trauma centers. Here in, we propose a protocol with conservative measures for the management of patients with severe traumatic brain injury. We managed a series of seven children who were successfully treated with this protocol between March 2013 and June 2013. Our protocol consists of following treatment modalities: >Intubation in all patients with severe TBI and using mechanical ventilation in all cases for the beginning>Sedatives and analgesics and pain management>Serial ABGs Q6h>Hyperosmolar therapy via hypertonic saline 5%>Correction of anemia, coagulopathy, hypoalbuminemia and maintaining normoglycemia>Early initiation of p. o. feeding via OG tube>Avoiding hypothermia>early detection of fever and extensive fever work-up and management of infections>Management of spasm >Postponing tracheostomy till up to 21 days>Avoiding EVD for ICP monitoring and relying on radiologic surveillance and clinical judgment especially the size and reaction of pupils Of 7 children managed by this protocol all patients were discharged with favorable condition. None of these patients underwent decompressive craniectomy, ventriculostomy for ICP monitoring and tracheostomy. Adelson et al published a guideline in 2003 for management of children with severe TBI which further evidence-based analysis marked no measures as «standard», three as «guidelines» and other recommendations as «options». Conservative management of children with severe TBI is not only cost-beneficial but also provides favorable outcomes. Radiologic surveillance and clinical judgement remains superior to ICP monitoring due to lower risk of fatal infections.

Cervical facet dislocations occur rarely in the setting of cervical spinal trauma in general, accounting for about 5%-10% of all cases. Considerable controversy exists especially regarding plausible prognostic factors, outcome, and treatment options. We considered all cases of unilateral or bilateral cervical facet dislocations admitted to a single university-affiliated center, to search for common prognostic factors, measure outcome, and evaluate the safety and efficacy of current treatment strategy performed in our center. In an ambidirectional cohort design, all cervical spinal trauma patients admitted to the only specialized trauma center affiliated to Shiraz University of Medical Sciences from Jan 2009 to May 2013 were evaluated. All patients underwent thorough imaging studies, cervical traction, and surgery using a specific protocol. Patients'' demographic, clinical, imaging and interventional data were retrospectively collected. Prospectively, patient''s functional outcome as rated by the modified Japanese Orthopedic Association (mJOA) Scale score, residual pain as scored on visual analogue scale (VAS), and the status of fusion, alignment and hardware integrity on follow-up cervical radiographs were evaluated. A total of 28 patients were admitted, 19 (68%) were unilateral and 9 (32%) were bilateral. Mean age at trauma was 41.1 ± 16.1; there were 22 (79%) male and 6 (21%) female patients. Motor-vehicle accidents were the cause of trauma in the majority of patients (93%). C5-C6 was the most common (43%) level involved, followed by C6-C7 (26%). There was a significant trend for the bilateral locked facets to occur at lower cervical levels. Lower cervical levels were also associated with a higher rate of associated trauma or fracture at other cervical levels or other parts of the body. ULF patients were most commonly intact (63% AIS E); while BLF patients were mostly quadriplegic (56% AIS A) (p value = 0.016). Closed reduction was performed with a mean weight of 9 kilograms (range: 4 – 17), and it was successful in 82% of cases. Male patients (p value = 0.03) and BLF patients (p value = 0.002) needed significantly higher weights for reduction. Eighty-six percent of patients were operated in a single stage operation, and anterior approach was used more commonly. Single posterior approach was used more commonly in patients with BLF (p value = 0.02), and in lower cervical levels (p value = 0.007). Only four patients required a second approach for a circumferential fusion. There were no surgery-related complications. The primary outcome parameter, total mJOA score was non-significantly higher in ULF (median: 18) than BLF (median: 9) patients, only the upper extremity motor and sphincter domains of the mJOA scale were significantly higher in ULF patients. Residual cervical pain at follow-up (sclaled on VAS) was not also different between two groups. The only predictor of outcome was neurological status of the patient on admission. There were only one long-term complication (mal-union and post-op kyphosis) in follow-up. Facet fractures, especially when bilateral, can cause significant neurological morbidity. We may have to expect a more complicated course and a more extensive approach in cases of bilateral locked facets, or injury at lower cervical levels. Our treatment strategy is effective and safe in short-term; and despite limited follow-up, seems to be also effective in long-term.

Vertebral hemangiomas are among the commonest benign primary spinal tumors. They usually assumed to be incidental findings in neuroimaging studies; however they can be symptomatic either because of their aggressive behavior or fracture in the affected vertebrae. There is a bulk data on natural course, diagnosis and treatment of these benign lesions in the literature, but few key points provided regarding their treatment when causing C2/odontoid fractures. 27 year old male who suffered minor head trauma after a motor vehicle accident, presented to the emergency room with a severe neck pain. No obvious functional neurological deficit was noted in the initial and further clinical evaluation. In routine neuroimaging studies there was a displaced type 2 odontoid fracture in the hemangiomatous C2 vertebrea. Based on our literature review external immobilization with a Halo-Vest and close fallow up was sought as the most appropriate treatment strategy. To date, good results have achieved in a very short term course of follow up. pathologic fracture in a hemangioamtous odontoid is a rare clinical situation. Given the paucity of published data, many questions relating to the nature and management of this condition need clarification.

Traumatic brain injury remains the leading cause of mortality and morbidity worldwide. With changes in demographic status, improvements in technology and introducing novel medical and surgical guidelines for management of TBI patients, regular evaluation of epidemiological profiles, injury severity classification, and outcomes are required. A form was designed to record demographic data, trauma event history and TBI-related variables such as GCS, pupils, brain CT findings, vital signs, arterial blood gas results, and final GOSE after 6 months follow up.From March 2010 till June 2012 all Patients with severe TBI admitted in Shahid Rajaee hospital affiliated to Shiraz University of Medical Sciences, Shiraz, Iran was reviewed. Available data were filled within the mentioned forms and then transferred to SPSS 16 software for analysis. Of 681 patients with TBI who had GCS≤10, 98(14.4%) were female and 583(85.6%) were male. The most frequent mechanism of trauma was motor-vehicle accident (MVA)(65%) followed by pedestrian (17.3%), fall (12.3), and assault injuries (5%). Mean age (±SD) of our patients was 36.1(±18) years with 68% were young (≤40y), 17.6% Middle-aged (40-59), and 14.1% Old (≥60).Six-months GOSE score of these patients, which shows 80% of our patients, had favorable outcome (GOSE>4) with 41% full recovery (GOSE=7&8). Shahid Rajaee trauma center which was one or the largest referral trauma centers in southern Iran has achieved similar favorable outcomes as other trauma centers worldwide which had presented their epidemiologic data.

Cranioplasty after post-injury decompressive craniectomy (DC) has been routinely performed as the second stage of the treatment. We describe the use of a bioresorbable sheet (Orthowrap®) in DC in order to prevent dural adhesion to overlying tissues. A retrospective analysis of 107 consecutive trauma patients who underwent emergent DC (due to subdural hematoma or intractable intracranial hypertension) and subsequent cranioplasty with autologous bone flap were performed. The technique involved unilateral hemicraniectomy and dural graft with pericranial fascia. A bioresorbable sheet (Orthowrap®) was placed between dura and overlying tissues in some patients (Case group) for protection from future adhesion formation. The development of adhesion formation was evaluated during the cranioplasty in terms of operation time and the amount of blood loss and compared between groups. Sixteen patients were female (14.9%) and 91 were male (85.1%). Cranioplasty was performed after a meantime of 54.5± 49 days following the DC. Comparing the Hb level before and after cranioplasty, the patients who had undergone craniectomy without the use of Orthowrap® had higher Hb drop than case group (2±1.1 vs. 1.7±1.1). Regarding the operation duration, less time was spent on cranioplasty of case group (125.4±41.8 vs. 130.6±41.8). However, the difference between these two parameters in case and control group was not statistically significant. In our study, DC with the use of a bioresorbable sheet (Orthowrap®) did not show statistically significant advantage over the conventional craniectomy in terms of amount of intraoperative bleeding and duration of operation. We think that a limitation to our study was the sample size.

Low back pain (LBP) is a common complaints in population which lower the quality of life. The main etiology of LBP is recognized just in about 20 % of patients, while in 80% of cases it has been attributed to lumbar disk herniation and causes some unnecessary lumbar surgeries without realizing the certain cause. Consequently, this study was planned to evaluate the etiologies of LBP in patients who had lumbar disc herniation to clarify whether the disc herniation is the main cause of patients` pain or other diseases rather than disc herniation are responsible for this kind of pain. In this cross sectional study, we analyzed the medical profiles of the patients with proven lumbar disc herniation in a private clinic in Mashhad City, Iran between 2005 and 2012 for demographic and the etiologies of LBP with clinical and paraclinical studies. We also calculated the incidence of each etiology in aid of SPSS software (version 13). In our study, among 1250 patients with proven lumbar disc herniation by MRI, 500(40%) patients had chronic LBP, and the most common causes of LBP were heavy constant working (40.2%), Osteoporosis (35.6%) and Sacro-iliac joint pain (34.6%) respectively, and interestingly the lumbar disc herniation as the cause of their LBP was in 9th rate. In this study we found that in spite of previous beliefs, discogenic etiologies are not common causes of LBP. Thus, even in patients with proven lumbar disc herniation by imaging, the physician should perform a thorough evaluation of the patient for other causes of LBP rather than lumbar disc herniation for avoiding unnecessary lumbar surgery.

Normal pressure hydrocephalus (NPH) is a progressive sub-acute or chronic disorder with a triad of clinical manifestations: 1) cognitive impairment 2) gait impairment 3) urinary incontinency. Radiological findings in NPH include: ventricular enlargement, periventricular signal changes, periventricular edema, increase Evans Index (at least 0.3), temporal horn enlargement and callosal angle of greater than 40°. One of the most important differential diagnoses of NPH is Alzheimer disease (AD). However, ventricular enlargement is common in a variety of dementing disorders and urinary and gait abnormalities are also common in the elderly. In this study, we want to compare the size of lateral ventricles, third ventricle, temporal horn, peri hippocampal fissure, Evans index and callosal angle in NPH and AD patients. In this study 45 participates divided into 3 groups: 1) NPH 2) AD 3) Control. At first all of participates received MMSE questionnaire. MRI findings of 3 groups compared with each other. We graded lateral ventricles, third ventricle, peri hippocampal fissure and temporal horn for size as a follows: 0=normal 1= mildly dilated 2=moderately dilated 3=markedly dilated. We also measured Evans index and callosal angle. Significant differences between the two groups were found for the size of lateral ventricles, third ventricle, perihippocampal fissure, temporal horn and callosal angle. However, there were no significant differences in Evans index between NPH and AD group. The degree of dilatation of peri hippocampal fissure and callosal angle appears to be sensitive and specific markers to differentiating AD from NPH because of very small overlap between two groups. Also we cannot found Evans index as a specific marker for diagnosis of NPH as reported in the past studies.

Despite numerous studies on pulsed electromagnetic field (PEMF) application, the effects of PEMF on intervertebral disc (IVD) have not yet been investigated in vivo. Accordingly, the effects of PEMF upon IVD in rats were evaluated through molecular surveys. Rats were divided into six groups: Group I and II were exposed to low and high frequency of PEMF (LF and HF respectively). Group III and IV underwent induced disc degeneration and were exposed to low and high frequency of PEMF (LF/IDD and HF/IDD, respectively). Group V underwent induced disc degeneration (IDD), and group VI was control. The values of caspase 3, Bax, Bcl-2 and β-actin band density, as cell apoptotic markers, were obtained from band densitometry. Our results showed that the value of cleaved Caspase-3 of cells and Bax/Bcl-2 ratio in IDD group increased significantly compared to the control group (p<0.001).The value of cleaved Caspase-3 and Bax/Bcl-2 ratio decreased significantly in LF/IDD and HF/IDD groups compared to IDD group (P<0.05). No significant increase was seen in the cell apoptotic markers in the groups just exposed to PEMF compared to the control group. There was also no significant decrease in the Bax/Bcl-2 ratio in HF/IDD and LF/IDD groups compared to the control group. These data suggest that PEMF attenuates degenerative processes in rat''s intervertebral discs and has no effect on normal discs. Regulations of the expression of apoptotic proteins may be one of the mechanisms by which PEMF is effective in reduce disc degeneration.

Despite a benign histological classification, the proximity of craniopharyngiomas to vital neurovascular structures and their high recurrence rates make them one of the most challenging and controversial management dilemmas in neurosurgery. Adherence to the pituitary stalk, hypothalamus, and vital neurovascular structures such as the optic apparatus, and various major/perforating vessels as well as diminutive intraoperative visualization, distorted anatomical relationships, and limited sharp dissection often hinders complete resection regardless of approach.Expanded endoscopic endonasal surgery (EES) has been recently used to access intrasellar and suprasellar craniopharyngiomas in a few institutions over the last decade with good results. With the increasing use of endoscopic techniques and the improved illumination and expansive view they provide, endonasal approaches have been shown efficacy and safety in treating of these tumors. The EES creates a ventral midline corridor to the sellar, suprasellar, and parasellar compartments that obviates the need for any brain retraction and provides an unprecedented view down the barrel of the tumor to the floor of the hypothalamus and roof of the third ventricle. In addition, unlike the microscope, which is limited by line of sight, the endoscope provides direct access to the long axis of craniopharyngiomas, a factor well recognized as critical for maximal, safe tumor resection without complications associated with brain retraction and extensive craniotomies. In performing a purely endoscopic resection, the main complications are primarily related to control of intracranial vessels, and skull base reconstruction with its associated risk of CSF leak, tension pneumocephalus, and meningitis. So, surgery requires a multidisciplinary team with significant EES experience and advanced equipment (angled endoscopes, endoscopic surgery instruments, image guidance, and neurophysiological monitoring) for safe results. In this regard, we present some precious technical notes and our experience to achieve optimized results.

Studies conducted by Zamboni et al. have suggested a new hypothesis that an abnormal drainage of venous blood due to stenosis or malformation of the internal jugular and/or azygous veins can be the cause of MS. They called this abnormality as “chronic cerebro-spinal venous insufficiency (CCSVI) could result in increased permeability of blood brain barrier, local iron deposition and secondary multifocal inflammation. In this presentation, we will discuss the more relevant scientific data related to this issue. Balloon angioplasty in a preliminary study by Zamboni improved symptoms in MS. High re-stenosing rates led authors to propose that the use of stents might be a better treatment than balloon angioplasty, although later they stated that stents should not be used. Balloon angioplasty and stenting have been proposed as treatment options for CCSVI in MS. Many patients who have had the surgical procedure report their improvements on social media websites such as structured patient databases and YouTube. Such stories are only anecdotal evidence of efficacy, and do not constitute a scientific proof of the efficacy of the treatment since for example, those who have had a positive result are more prone to post their cases than those who had little or no improvement, and the reported improvements in patients'' condition can be attributed to the placebo effect. Because there is a lack of research evidence to suggest that this is a safe or effective treatment for people with MS, we do not recommend that people undergo this procedure outside of a properly-regulated clinical trial.

The study of educational programs and its'' association with clinical outcome in patients after neurosurgery appear to be important. There is a link between different method of teaching and supporting with clinical outcome after neuo-surgery. The aim of this study was to examine the significance of education agenda in relation to patients'' outcome after neurosurgery. A cross sectional study was carried out at the Isfahan Neurosurgery Ward located at the Isfahan/Kashani Hospital. Study was performed on adult patients after neurosurgery due to different etiology. Demographics, planned educational program and other necessary information were noted in d-Base. Statistical analyses were performed using SPSS for windows. Previous publication reported that educational program after neuro-surgery could influence quantity and quality of life. In some patients medication awareness and social support needs education program. It is well established that pharmacotherapy-teaching techniques could diminish the stage of anxiety and sadness. To improve care in order to maximize treatment effectiveness after neuro-surgery, teaching supervision could provide precious final medical decision for neurosurgeons. Our preliminary observation predicts that teaching program in patients after neuro-surgery could increase patients'' awareness related to disease, its'' progression, treatment and drugs adverse effects.

Mesial temporal structures are notorious causes of epilepsy and although they have placed in strategic anatomical location they have been removed ending to epilepsy control and even cure. Amygdala well known element in limbic system has documented role in epileptogenesis located across the temporal horn just above the hippocampus and despite its famous neighbor has no clear and anatomically reliable boundary to its nearby indispensable neural structure like internal capsul basal ganglia and optic pathway. Its critical location make its removal very perilous and limited action. Among the mesial temporal surgeries (113 cases) during 2005-2013 46 cases for MTS and 67 cases temporal lobe tumors involving mesial structurs 4 cases can be considered primary amygdal tumors and one cases due to autohippocampectomy by temporal horn epidermoid which has made amygdal region the only culprit of epilepsy ethiology has been selected. In this regards we discuss fully surgical strategy and approach to this very rare lesion and especially crucial role of neuronavigation in reaching this deepest epileptogenic focus in human brain. And anatomical relationship and how the epilepsy surgeon should care about them will demonstrated although primary amygdal tumors are rare they are one of most challenging neurosurgical task and its safe treatments demand careful and well judgmental surgical decision making and practice. Profound Knowledge of anatomy mastering microsurgical skill and use of modern neuronavigation tools will help the surgeon end up with beautiful surgery, saving important neural structure and cured and well saved patient.

Brain tumors of all histological classifications and cell origins, account for great mortality and morbidity worldwide. For many types, especially high grade forms, five-year survival and success rate of surgical treatment is considerably low. This explains why several recent studies have focused on introduction of effective medical therapeutic approaches for treatment of these tumors. Genistein is a member of isoflavonoid family which is proved to have anticancer effects in breast, prostate, and SCCs of various origins. In this article we identify therapeutic effects of Genistein in low grade and high grade gliomas and meningioma. High grade glioma, low grade glioma and meningioma tumors tissue samples were obtained from a total number of 15 patients. Tumor tissues were firstly washed with PBS, cut into small pieces, digested with Collagenase type 1 and cultured in the tissue culture flask containing DMEM and 10% FBS. In passage 3 of culture, cells were treated with different concentrations of Genistein (0,0.01, 1/250,1/500 and 0.001 M) for 72 hours and then IC50for both treated and untreated cellswas evaluated with 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay. Expressions of Fas, p53 and Bcl-2 level were determined using quantitative Real-Time PCR, before and after treatment with Genistein. Data were compared among the case and control groups within studied tumor types and analyzed using Kruskal-Wallis and Mann-Whitney U test. The results were remarkable for significant reduction of cell viability parameters in Genistein-treated groups of all studied tumor types versus the control groups. This finding comes with documented significant alterations in Fas pathway expression in meningioma and HGG. Also P53 was markedly elevated in HGG, although it was not statistically significant Results of this study along with previous documentations of anticancer properties of Genistein in other malignancies of various organs, indicates that this compound can effectively act towards tapering of malignant behavior, angiogenesis, and invasion of malignant brain tumors.

Surgical strategy for thoracic disc herniation (TDH) remains contraversial. We have performed posterior thoracic interbody fusion by transfacet pedicular sparing approach and laminectomy with pedicle screw fixation. The objectives of this retrospective study are to demonstrate the surgical outcome of transfacet pedidular sparing approach for thoracic disc herniation. In our department we have enrolled 21 patients who underwent transfacet pedicular sparing approach and laminectomy for myelopathy due to thoracic disc herniation were followed at least one year. The mean age of patient at surgery was 48.6 years and the average period of follow up was 1.4 year. The level of the operation were T11-T12 in 6 cases, T10-T11 in 5 cases, T8-T9 in 1 case, and T5-T6 in 1 case and T12-L1 in 6 cases and T11-L1 in 2 cases respectively. The pre and post clinical status was evaluated according to JOA score and ODI. Additionally, post-Op complications were assessed. Average pre and post operation JOA score were 4.1 and 8.5 points respectively. Improvement of ODI was observed in all but one patient. Bony union was observed in all cases. CSF leakage was observed in one patient post operatively with neither neurological deficit nor evidence of infection. Transfacet pedicular sparing approach and laminectomy has produced satisfactory outcome for myelopathy due to thoracic disc herniation. Therefore, in transfacet pedicular sparing approach and laminectomy is one of the surgical treatment of choice for patients with thoracic disc herniation causing myelopathy.

Nowadays Medical equipment plays an important role in the treatment and in the medical education. Using outdated preventive maintenance (PM) system may cause problems in the cutting edge medical equipment, Nervous system disease''s equipment (In diagnosis and treatment) which are crucial for every medical center. Based on above facts we focused on nervous system treat units’ equipment and informed the supervisors and their colleagues about the latest equipment maintenance status and promoted methodical and correct method to be used for medical equipment maintenance. This research is an analytical descriptive and has been done on the base information from a particular time to past. We gathered our required information of 2013 from Alzahra Medical Center. We divided this research info 2 main phases. In the first phase, we picked out neurosurgery and neurology diseases medical equipment (diagnosis and therapy equipment) and in the second phase, we need to implement a methodical PM for every equipment. Research has shown that there are 19 nervous system equipment in Alzahra medical center, categorized in diagnostic (13 pcs), therapeutic (4 pcs) and diagnostic-therapeutic (2 pcs). As we declare in methods part of this research, we categorized medical equipment in Food and Drug Administration (FDA) segmentation. Capital-scarce equipment: Magnetic resonance imaging, Eco Doppler, Kamalaarak ultrasonic surgical aspirator, Stereotactic, computed tomography-scan, euroendoscope/vital-scarce equipment: Coblation, Sonoco, vaterjet/scarce equipment: Transcranial color Doppler, electroencephalogram, electromyography, surgical microscope. Survey of application and preventive maintenance of neurosurgery and neurology medical equipment in Isfahan Alzahra hospital show there is no P.M system. Implementing a complete P.M system for this medical center is crucial to preventing cause problems for these medical equipment and decreasing maintenance costs and gaining uptime. Researchers of this article have tried to provide PM, use of texts, web and experts.

Skull base tumors are one of the challenging lesions for every neurosurgeon because of benignity and technological advances in recent years. Review of approaches and results of our operations and complications. We studied retrospectively our patient''s documentations 1385-1391 in Shahriar and Alinasab hospital. Fifty two cases (52) includes; 26 meningioma, 16 hypophiseal adenoma, 4 acoustic schewanoma, 2 trigeminal schewanoma, 2 epidermiod cyst, 1 fibrous dysplasia, 1 chemodetoma. Six of the 52 patients died because of (1) vascular instability two cases (meningioma, trigeminal schewanoma), (2) pneumonia 1 case (adenoma), (3) increased intracranial pressure and edema 1 case, (4) pulmonary emboli 1 case, (5) temporal edema. Advances in microsurgical techniques and approaches of skull base surgery have promoted the outcomes of these tumor surgeries, even in general center without advances equipment.

Auditory temporal processing is the main feature of speech processing abilities which including temporal resolution, temporal ordering, temporal integration and temporal masking. Even though the patients with temporal lobe epilepsy have normal hearing, they may show speech recognition disorders. This study aimed to compare the auditory temporal processing in patients with left and right temporal lobe epilepsy. In this cross sectional non-interventional study, 25 patients with Temporal Lobe Epilepsy (TLE) with mean age of 31.1 years including 11 patients with Right Temporal Lobe Epilepsy (RTLE) and 14 patients with Left Temporal Lobe Epilepsy (LTLE) were evaluated by gap in noise (GIN) and duration pattern sequencing (DPS) tests. Results were compared with t-test analysis. There was no significant difference between patients with RTLE and LTLE in GIN test (p>0.05). But there was significant difference between patients with RTLE and LTLE (p=0.000) in DPS test. Patients with temporal lobe epilepsy have difficulties in temporal processing performances. Difficulties are more significant in patients with LTLE since the left temporal lobe is specialized for the processing of temporal information especially for the temporal ordering.

Traumatic brain injury (TBI) is known as one of the most important causes of mortality in middle age population. The aim of this study was to evaluate Gabapentin effect in improvement of consciousness level of these patients. This randomized clinical trial was done in March 2008 to September 2009. 60 patients from neurology clinics of Kashani hospital, Isfahan were divided into two groups of 30 subjects as the case and control groups randomly. The groups were treated by 300 mg Gabapentin and placebo twice a day for two weeks. The electroencephalogram (EEG), Glasgow Outcome Scale (GOS) results and Glasgow Coma Scale (GCS) findings were evaluated in all patients before and one week after intervention. The means of GCS and GOS before and after treatment were not different significantly between groups. This study showed significant change in EEG patterns after treatment with gabapentin. Gabapentin might not be suggested for management of unconsciousness due to TBI.

Lumbar disc number 1 and 2 (L1 and L2) although anatomically located in lumbar region but it is specific location pose a caveat to surgeon to presage for conus medullaris and also for its great biomechanical standpoint in thoracolumbar region. In our experience with this group of patients we used transfacet pedicle sparing approach to care for conus and also we performed short segment fusion to augment this highly demanding biomechanical region. From 2008 till now we operated 13 cases with L1-L2 disc underwent operations with this technique and after operation received Jewett hyperextension brace for 3 months. One patient because of central hard calcified disc received thoracoabdominal approach and from anterior got decompression. All surgery performed under high magnification of microscope and bone removal was done by powered drill. In About 6 case decompression was performed bilaterally to reach the central portion of the disc. In all patients pedicle screw was used for fixation, in 5 TLIF banana cage was also used and in 4 cases spinous process bone used as interbody graft. Only 2 cases presented with severe L2 radiculopathy and another 11 patients came with feature of cauda equine or conus problem. Axial back pain was crucial symptom in 8 cases. In 2 patients there is multiple discs with L2-L3 and one with T12-L1. There was no aggravation in neurological deficit and we have no problem with CSF leak or wound. Fusion achieved in all patients and axial back pain resolved successfully. We suggest that L1-L2 although innately considered a lumbar disc should be regarded and considered as thoracic disc and the surgeon should not rely only on where the conus terminated in MRI. Small traction there can lead to catastrophic neurological damage. Therefore by using transfacet pedicle sparing under microscopic guide the cord should be decompressd by drill and not putting kerisson under already stenotic canal if neurological injury would be prevented.

Trigeminal neuralgia is one of the most persecutor pains of the face. Pain is usually lancet form and aggravates with eating and speaking. Gamma knife radiosurgery is used for treatment of refractory pain.In this study we evaluated effect of gamma knife on proximal site of trigeminal nerve adjacent to inducement artery. In this retrospective study, 212 patients (age:50±10 year) between 2002 – 2011 selected in Iran Gamma Knife Center and divided to two groups. 180 patient without arterial pressure site emplacement and 32 with accurate definition of proximal nerve to artery, underwent gamma knife radiosurgery. From the 180 patients that arterial compression site on fifth cranial nerve was not defined, gamma knife radiosugery led to facial pain reduction or improvement in 75% of patients during the first year, while this rate was 90% in 32 patients of group 2. These proportions decreased to 60 and 80 percent in the end of second year, respectively. Impossibility to determine the exact location of arterial site near to the fifth nerve in all patients. Our study shows that localization of arterial compression site of involved trigeminal nerve results in significant increase in improvement or pain reduction after Gamma knife. Gamma knife planning by determining the location of the proximal nerve adjacent to the artery.

Trigeminal neuralgia is one of the most persecutor pains of the face. Pain is usually lancet form and aggravates with eating and speaking. Gamma knife radiosurgery is used for treatment of refractory pain.In this study we evaluated effect of gamma knife on proximal site of trigeminal nerve adjacent to inducement artery. In this retrospective study, 212 patients (age:50±10 year) between 2002 – 2011 selected in Iran Gamma Knife Center and divided to two groups. 180 patient without arterial pressure site emplacement and 32 with accurate definition of proximal nerve to artery, underwent gamma knife radiosurgery. From the 180 patients that arterial compression site on fifth cranial nerve was not defined, gamma knife radiosugery led to facial pain reduction or improvement in 75% of patients during the first year, while this rate was 90% in 32 patients of group 2. These proportions decreased to 60 and 80 percent in the end of second year, respectively. Impossibility to determine the exact location of arterial site near to the fifth nerve in all patients. Our study shows that localization of arterial compression site of involved trigeminal nerve results in significant increase in improvement or pain reduction after Gamma knife. Gamma knife planning by determining the location of the proximal nerve adjacent to the artery.

To develop an artificial neural network (ANN) model to determine a sound method for selecting patients for surgery or non-surgical options and to compare it with the traditional approach in lumbar spinal canal stenosis (LSCS) patients. An ANN model and a logistic regression (LR) model were used as predicting models. Fifteen factors were recorded as the input variables for developed ANNs and LR: Age, gender, duration of symptoms, and measures of visual analog scale (VAS) of leg pain/numbness, the Japanese Orthopaedic Association (JOA) Score, the Neurogenic Claudication Outcome Score (NCOS), the Oswestry disability index (ODI), the Swiss Spinal Stenosis Score (SSS), the stenosis bothersomeness index (SBI), the dural sac cross-sectional surface area (DSCA), the Stenosis Ratio (SR), the Self-Paced Walking Test (SPWT), morphology grade presented by Schizas et al. and grading system introduced by Lee et al. Successful outcome was recorded based on the criteria presented by Stucki et al. ANNs were fed with patients’ data in order to choose surgical versus non-surgical treatment options. Sensitivity analysis was applied for the developed ANN model to identify the important variables. Receiver operating characteristic (ROC) analysis, Hosmer-Lemeshow (H-L) statistics and accuracy rate were calculated for evaluating the two models. The data for a total of 346 of 379 patients (143 male, 203 female, mean age 59.5±11.5 years) were available for the analysis. Patients’ information was divided into training (n = 174), testing (n = 86), and validation (n = 86) data sets. Successful outcome were 93.4% (surgery) and 89.4% (non-surgery) at 1-year follow-up. The SR, morphology grade and grading system were important variables identified by the ANN. The ANN model displayed better accuracy rate (97.8 %), a better H-L statistic (41.1 %) which represented a good-fit calibration, and a better AUC (89.0%), compared to the LR model. The findings showed that an ANN model can predict the optimal treatment choice for LSCS patients in clinical setting and is superior to LR model. Our results will need to be confirmed with external validation studies.

The purpose of this study was to develop an artificial neural networks (ANNs) model for predicting 2-year surgical satisfaction and compared with traditional predictive tool in LSCS patients. The two prediction models included an ANN model and a logistic regression (LR) model. The age, gender, duration of symptoms, walking distance, visual analog scale (VAS) of leg pain/numbness, the Japanese Orthopaedic Association (JOA) Score, the Neurogenic Claudication Outcome Score (NCOS) and the Stenosis Ratio (SR) values have been determined as the input variables for the developed ANNs and LR model. Patient surgical satisfaction was recorded by using standardized measure. ANNs were fed patient data in order to predict 2-year surgical satisfaction based on several input variables. Sensitivity analysis to the developed ANN model was applied to identify the important variables. The area under a receiver operating characteristic (ROC) curve (AUC), Hosmer-Lemeshow (H-L) statistics and accuracy rate were calculated for evaluating the two models. A total of 168 (59 male, 109 female, mean age 59.8±11.6 years) patients were divided into training (n = 84), testing (n = 42), and validation (n = 42) data sets. Post-surgical satisfaction was 88.7% at 2-year follow-up. The SR was important variable selected by the ANN. The ANN model displayed better accuracy rate in 96.9% of patients, a better H-L statistic in 42.4% of patients, and a better AUC in 80.0% of patients, compared to the LR model. The findings show that an ANNs can predict 2-year surgical satisfaction for use in clinical application and more accurate compared to LR model.

This study aimed to investigate about epidemiology of brain metastases using information from the Iranian Gamma-knife Centre. This was a retrospective study. In all 5216 case records of patients who referred to the Iranian Gamma-knife Centre for treatment of brain tumors during year 2003 to 2011 were reviewed. Data were explored to find out brain metastases due to cancer and assess the information as applied to cancer patients including survival analysis. Two hundred and twenty patients were identified as having brain metastases due to cancer. The mean age of patients were 54.0 (SD = 12.7) years and were followed for an average of 7 months after treatment with Gamma-knife. The median survival times for the GPA were: GPA 0–1, 4±0.4 months; GPA 1.5–2.5, 6±0.7 months; GPA 3, 9±0.9 months; and GPA 3.5–4.0, 12±1.8 months and overall survival were 7.0 (SD = 0.6) months. The findings suggest that many cancer patients in Iran might develop brain metastasis. Although this is not a very high incidence compared to the existing statistics from other countries, there is urgent need to explore the issue further.

Lumbar disc hernia (LDH) and lumbar spinal stenosis (LSS) are the most common diagnoses of low back and leg pain symptoms. The Core Outcome Measures Index (COMI) is a measure of health related quality of life in these patients. This study aimed to cross-culturally translate and validate the COMI in Iran. This was a prospective clinical validation study. The translation and cross-cultural adaptation of the original questionnaire was performed in accordance with published guidelines. A total of 121 patients with LDH or LSS were asked to respond to the questionnaire at two points in time: pre- and post-operative assessments (6 months follow-up). The Oswestry Disabiltiy Index (ODI) also was completed for patients. To test reliability the internal consistency was assessed by Cronbach''s alpha coefficient and validity was assessed using convergent validity. Responsiveness to change also was assessed comparing patients’ pre- and postoperative scores. The Cronbach’s alpha coefficients for the COMI at preoperative and postoperative assessments ranged from 0.79 to 0.82 indicating a good internal consistency for the questionnaire. The change in the ODI after surgery was strongly correlated with change in the COMI, lending support to its good convergent validity (r = 0.78; P < 0.001). In addition, the correlation of each item with its hypothesized subscale of the COMI showed satisfactory results suggesting that the items had a substantial association with the subscale representing the concept. Further analysis also indicated that the questionnaire was responsive to change (P < 0.0001). In general, the Iranian version of COMI performed well and the findings suggest that it is a reliable and valid measure of back pain evaluation among LDH and LCS patients.

Treatment of cavernomas remains a challenge in surgically inaccessible regions. The purpose of this study was to evaluate outcomes after Gamma-knife surgery (GKS) for these patients. A retrospective review of 100 patients treated between 2003 and 2011 was conducted in order to evaluate hemorrhage rates, complications, radiation effects after GKS. Dosage at the tumor margin was stratified into two groups: those that received less than or equal 13 Gy; and those who received more than 13 Gy. The demographic and clinical characteristics of patients including age, gender and hemorrhage rates were extracted from care records. The median age was 32.5 years (ranging from 5 to 79). 44% were female. The median follow-up time was 42.2 months (ranging from 24 to 90). The median volume of the lesions was 1050.0 mm3 (ranging from 112.0 to 4100.0) before GKS. A reduction of 27.5% in median size of cavernomas was achieved at the last follow- up. There was 12% treatment-related morbidity after GKS. The hemorrhage rate in the first 2 years after GKS was 4.1%, and 1.9% thereafter. There was no mortality due to GKS and 93 patients were alive at the last follow-up. The radiation-related complication developed with marginal dose 13 Gy. The GKS for cavernomas appears to be a safe and beneficial in carefully selected patients. Low-dose GKS may be effective for the management of CMs.

To study the correlation between the grading and the severity of symptoms in patients with lumbar central canal stenosis (LCCS) and evaluation of surgical satisfaction. Grading of LCCS on MRI was determined. The severity of symptoms was evaluated based on the duration of symptoms, walking distance, VAS of leg pain/numbness, the NCOS and the JOA score. We studied distribution of grades, relation between grading and severity of symptoms. We determined patient satisfaction using standardized measure. Mean age was 61.2 years. 70% were female. All of patients were grades-2 (n = 56) and 3 (n = 28). The symptoms were significantly worse in patients with grade- 3. The walking distance in the patients with grade- 3 was significantly shorter than those with grade-2. In addition, the VAS of leg numbness in patients with grade-3 was significantly higher than those with a grade-2. The JOA and the NCOS scores were significantly lower in patients with grade-3. Post-surgical satisfaction was 90.5%. The findings show that the patients’ symptoms, walking activity and functionality in grade-2 are better than grade-3. Based on outcome, it seems that patients with grade-3 is satisfied than grade-2.

To study the quality of life (QoL) outcomes in patients with lumbar spinal stenosis (LSS). Patients that had undergone surgery for LSS entered into this cross sectional study. Demographics, duration of symptoms, walking distance and grading stenosis based on MRI were determined. Pre-operative and 6-month and 1- and 2 -year post-operative QoL outcomes by using a Japanese Orthopedic Association Back Pain Evaluation Questionnaire (JOABPEQ), Short Form-36 scores (SF-36) questionnaire and visual analogue scale (VAS) for pain in 142 patients were analyzed. Median age of the patients was 59.9 ± 10.1 years. 40.1% were men. All of patients were grades C (n = 101) and D (n=41). Median follow-up time was 2.9± 0.9 years. There was significant reduction in the severity of back pain (VAS, p < 0.05) at 6-month and 1- and 2 -year. There was significant improvement in all aspects of the Quality of Life (JOABPEQ and SF-36, p < 0.05) scores except for general health subscale of SF-36 at 6-month and 1- and 2 -year post- operation. The findings suggest that surgery procedure offers significant and valuable improvement in QoL outcomes for the LSS patients.

RMDQ-24, NCOS, ODI, JOA, SSS and COMI have been regularly used to measure functional outcomes in patients with lumbar spinal stenosis. The aim of this study was to compare COMI score versus other measures and to see if there were correlations among the measures studied. A sample of patients with lumbar spinal stenosis candidate for surgery entered into the study. Patients completed the questionnaire twice: at pre- and post-operative assessments. The correlation between the COMI and other measures were examined for both assessments. one hundred and twenty patients were eligible to enter into the study. The mean age of patients was 49.4± 9.8 (ranging from 46 to 79) years. Spearman’s correlation test showed significant correlations among the COMI and the RMDQ-24 (r =0.83), NCOS (r =0.82), ODI (r =0.79), JOA(r =0.80) and SSS (r =0.79) at pre-operative assessment. Similarly there were significant correlations between the COMI and other measures at post-operative assessment as follows: RMDQ-24 (r =0.87), NCOS (r =0.84), ODI (r =0.82), JOA (r =0.83) and SSS (r =0.84) (P< 0.001). RMDQ-24, NCOS, ODI, JOA, SSS and COMI score have a strong correlation in measuring disability in a group of patients with lumbar spinal stenosis.

Osteoporosis is a very common disease of bone, and vertebral fracture. The Quality of Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41) is a tool of health related quality of life in these patients. This study aimed to cross-culturally translate and validate the QUALEFFO-41 in Iran. This was a prospective clinical validation study. Forward-backward procedure was used to translate the questionnaire from English into Persian. The translation and cross-cultural adaptation was made in accordance with published guidelines. Patients were divided into two study groups, according to World Health Organization criteria: with at least one vertebral fracture, which had been surgery and with OP and no fractures as a control group. All of the participants were assessed by both QUALEFFO-41 and SF-36. Surgery group was asked to respond to the QUALEFFO-41 at two points in time: pre- and postoperative assessments (6 months follow-up). To test reliability the internal consistency was evaluated using Cronbach''s alpha coefficient. Validity was evaluated by performing convergent validity between the QUALEFFO-41 and the SF-36 and Item-scale correlations, and discriminatory ability. Internal responsiveness of the QUALEFFO-41 to the clinical intervention (surgery) also was evaluated comparing patients’ pre- and postoperative scores. In all 149 patients were completed the questionnaire, 48 patients with surgery, and 101 patients as a control group. The QUALEFFO-41 at pre- and postoperative assessments showed adequate internal consistency in all domains (Cronbach''s alpha of 0.71 to 0.81). Additionally, the correlation of each item with its hypothesized domain of the QUALEFFO-41 indicated acceptable results suggesting that the items had a substantial relationship with its own domain. Further analysis also indicated that the questionnaire was responsive to change (P < 0.0001). Significant correlations existed between scores of similar subscales of QUALEFFO-41 and the SF-36 (P < 0.001). The findings show that, the Iranian version of QUALEFFO-41 is a reliable and valid measure of functionality and quality of life evaluation among patients with osteoporotic vertebral fracture.

The aim of this study was to evaluate to elucidate independent factors to predict surgical satisfaction in lumbar spinal canal stenosis (LSCS) patients. Patients who underwent surgery were grouped based on the age, gender, duration of symptoms, walking distance, Neurogenic Claudication Outcome Score (NCOS) and the stenosis ratio (SR) described by Lurencin. We recorded on 2-year patient satisfaction using standardized measure. The optimal cut-off point in SR, NCOS and walking distance were required for predicting surgical satisfaction from sensitivity and specificity calculations and receiver operator characteristic (ROC) curves. One hundred fifty consecutive patients (51 male, 99 female, mean age 62.4±10.9 years) were followed up for 34±13 months (range 24-49). One, two, three and four level stenosis was observed in 10.7%, 39.3%, 36.0 % and 14.0% patient, respectively. Post-surgical satisfaction was 78.5% for the 2 years follow up. In ROC curve analysis, the asymptotic significance is less than 0.05 in SR and the optimal cut-off value of SR to predict worsening surgical satisfaction was measured as more than 0.52, with 85.4% sensitivity and 77.4% specificity (AUC 0.798, 95% CI 0.73-0.90; P < 0.01). The findings show that the SR could be a preferred parameter for predictable to surgical satisfaction compared to walking distance and NCOS in Iranian population into clinical practice.

This study aimed to correlation between the grading stenosis and the SBST in patients diagnosed with lumbar central canal stenosis (LCCS). This was a prospective clinical study. A total of 269 patients with LCCS were asked to respond to the questionnaire at their first visits. Grading of LCCS on MRI was determined. The severities of symptoms were evaluated using grading of MRI. Finally grading on MRI and calcification of the SBST were determined, and sensitivity analysis carried out to evaluate severity of LCCS on grading of MRI using the SBST. The mean age of patients was 58.6 (SD= 10.9) years; and 56.5% were female. According to patients’ imaging they have been diagnosed as grade1 (n = 86), grade 2 (n = 107) and grade 3 (n = 76). The sensitivity, specificity and accuracy of the estimated grading of LCCS on MRI for low, medium, and high risk groups were found to be desirable: 97.6%, 66.7%, 96.5% for low risk; 93.1%, 83.3%, 92.5% for medium risk, and 97.2%, 66.7%, 94.7% for high risk. Our findings indicate that grading of LCCS on MRI correlate with SBST and suggest that it is a reliable measure for screening LCCS patients

Artificial neural networks (ANNs) can be used as a measure for clinical decision- making process. The aim of this study was to develop an ANN model to predict 6-month success of the endoscopic third ventriculostomy (ETV) and compared it with traditional predictive measures in childhood hydrocephalus. An ANN, ETV Success Score (ETVSS), CURE Children’s Hospital of Uganda (CCHU) ETV Success Score (CCHU ETV) and a logistic regression (LR) models were applied to predict outcomes. The etiology, age, Choroid plexus cauterization (CPC), previous shunt, gender, type of hydrocephalus (TOH), and body weight were considered as input variables for established ANN model. To do so data from childhood hydrocephalus patients who had ETV surgery were trained to predict successful ETV by several input variables. Successful ETV outcome was defined as the absence of ETV failure within 6 months follow-up. Then, sensitivity analysis was performed for the established ANN model to identify the most important variables that predict outcome. The area under a receiver operating characteristic (ROC) curve (AUC), accuracy rate of predicting, and Hosmer-Lemeshow (H-L) statistics were measured in order to test different prediction models. In all the data for 168 patients (80 male, 88 female, the mean age 1.4 ±2.6 years) were analyzed. They were divided into three groups: training group (n=84), testing group (n=42), and validation group (n=42). Successful ETV outcome was 47% as the absence of ETV failure within 6 months follow-up. The etiology, age, CPC, TOH, and previous shunt were the most important variables that were indicated by the ANN analysis. Compared to the ETVSS, CCHU ETV, and the LR models, the ANN model showed better accuracy rate (95.1%); the H-L statistic (41.2 %); and AUC (0.87 %). The findings show that ANNs can predict 6-month successful ETV with a high level of accuracy in childhood hydrocephalus diseases. Our results will need to be confirmed with further prospective studies

To evaluate the technique of surgery in the treatment and reconstruction of sphenoorbital meningioma (SOM). Patients undergoing surgery for SOM were included and were retrospectively assessed. The demographic and clinical characteristics of patients were extracted. Frontotemporal (pterional) craniotomy was performed. The greater wing of the sphenoid ridge was removed to the lateral limit of the lesser wing. When hyperostotic, the anterior clinoid was removed extradurally and the superior orbital fissure (SOF) was unroofed. The optic canal was unroofed, either intra- or extradurally, and the inferior optic strut was removed. When intracranial or intraorbital soft tissue was present, it was resected. Dural defects were reconstructed with autologous fascia lata. The roof and lateral wall of the orbit were reconstructed with titanium mesh. If there was a large cavity between the orbital and dural reconstruction and the cranioplasty, an autologous fat graft was used, and the sphenotemporal bone defect was covered with a titanium mesh cranioplasty. Six patients (6 females) and the median age were 45.6 years. Six patients had proptosis (mean±SD = 6.1±2.8 mm) and normal vision (n=2), decreased vision (n=3), and one patient had no light perception (NLP) at preoperatively. The left and right orbits were involved in 4 and 2 patients, respectively. A substantial reduction of proptosis was attained in all of patients. Surgery for patients with SOM improved vision in 3 of 4 cases (75%) and a patient who is NLP, remained unchanged. The technique of reconstruction of SOM appears to be a safe and effective in patients and is recommended.

This study aims to evaluate the self-administered, self-reported history questionnaire (SSHQ) to identify types of lumbar spinal stenosis (LSS). This was a prospective clinical study. A total of 235 patients with LSS were asked to respond to the SSHQ. All these patients recovered following surgical treatment. The LSS patients’ classification was derived based on history, physical examinations, and imaging studies. It is considered a gold-standard. Radicular and neurogenic claudication types of LSS based on SSHQ introduced by Konno et al. Two categories of LSS were determined based on SSHQ tool and gold-standard. Finally, sensitivity analysis carried out to evaluation of diagnostic values of SSHQ. The mean age of patients was 59.4 (SD=11.3) years; and 58.3% were female. According to gold standard criteria, patients have been diagnosed as radicular type (n = 103), and neurogenic claudication type (n = 132). The questionnaire had sensitivity, specificity and accuracy to be desirable in diagnosing for categorization of two types of LSS: 97.8%, 66.6%, 96.8% for radicular type, and 97.0%, 80.0%, 95.7% for neurogenic claudication type. Our findings indicate that the SSHQ is a reliable measure and may be a clinical diagnosis support tool between the two types of LSS patients.

In a trauma patient detecting the cervical spine injuries is one of the most important matter because undetected injuries in the cervical spine may result in severe neurological disability probably quadriplegia. Thus radiography of the cervical spine is considered mandatory in initial evaluation of a trauma patient according to the Advanced Trauma Life Support (ATLS). This approach results in high number of normal radiographies which can be referred as unnecessary radiographies. Thus we performed this study in order to determine the role of routine cervical radiography in initial evaluation of stable high energy blunt trauma patient. This was a prospective cross-sectional study including all the hemodynamically stable high energy blunt trauma patients with negative cervical physical examination referring to our trauma center during a 5-month period (May to September 2010). Cervical radiographies, computed tomography (CT) scanning and magnetic resonance imaging (MRI) were performed and reviewed for abnormalities. During the study period, 1679 high energy blunt trauma patients referred to our center out of which 400 were hemodynamically stable and had negative cervical physical examination. Cervical radiographies were found to be normal in all the patients. Cross-table cervical spine radiographies can be limited to those high energy blunt trauma patients who have positive cervical physical examination or those in whom physical examination is not revealing. These radiographies also have low value for detecting occult cervical spine fractures and CT imaging is considered the modality of choice in these cases.

ACDF is considered a standard neurosurgical treatment for degenerative diseases of cervical intervertebral discs. There are different materials used to restore physiologic disc height and enhance spinal fusion, but the ideal device has not been identified yet. To overcome this, we designed a new, inexpensive Acrylic cage. This study aims to compare polyetheretherketone (PEEK) cage with a novel Acrylic cage to find out which fusion cage yielded better clinical outcomes following anterior cervical discectomy and fusion (ACDF). In a prospective clinical study, a total of 64 patients were randomly allocated to undergo ACDF either with Acrylic interbody fusion cage made of polymethylmethacrylate filled with bone graft (n=32) or PEEK cage (n=32). Nurick’s grading was used for quantifying the neurological deficit. Clinical and radiological outcome was assessed preoperatively, immediately after surgery, and subsequently at 2, 6, and 12 months follow up. Odom''s criteria were used to evaluate the clinical outcomes of the patients. There was no significant difference in the age and sex distribution. There was no statistically significant difference in disc space height, intervertebral angel, and fusion status between the two groups, but there was a statistically significant improvement in the clinical outcomes of the Acrylic cage group compared with the PEEK cage group (mean difference: -0.438, 95% CI -0.807 to -0.068; p=0.016). This study suggests that the use of Acrylic cage is associated with good clinical and radiological outcomes and it can be therefore a good substitute for bone graft and other cages in ACDF.

Thunderclap headache is an acute type of headaches which causes 1% of patients with headache referring to Emergency department. The cause of this type of headache is a serious pathology in brain which results in high mortality rate. The aim of this study is to evaluate the distributive frequency of thunderclap headache causes during one year of observation. This observational analytical study conducted on the patients with thunderclap headache referred to Department of Neurology, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran from June 2009 to June 2010. Data received from 60 patients’ filled questionnaires and the causes were evaluated by Brain CT scan, lumbar puncture (LP) and other imaging such as Brain MRA, Brain MRI and cerebral angiography. Data were analyzed by SPSS 18.0 using t-student and chi-square tests. The most common complaint was severe headache without any signs in 44 cases (73.3%). There were 16 cases with severe headache associated to additional signs such as loss of consciousness in 10 (16.7%), hemiparesis in 1 (1.7%), continuous headache in 1 (1.7%), seizure in 2 (3.4%) and severe neck pain in 1 patient (1.7%). Brain CT scan was normal in 13 patients (21.7%0). 36 patients had subarachnoid hemorrhage (60%), 3 patients had intracerebral hemorrhage (5%), 6 patients had intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) in their CT scans. From 13 patients with normal Brain CT scan, 11 patients accepted LP who 8 of them had normal result and 3 patents had SAH. Thunderclap headache has high mortality rate and rapid accurate diagnosis can be lifesaving. Use of Diagnostic tests appropriately based on indications can guide physicians to correct diagnosis in a cost effective manner. In this study, LP improved 27% the accuracy of diagnosis in thunderclap headaches.

The aim of this study is to demonstrate our primary experience in endoscopic treatment of obstructive hydrocephalus caused by intracranial lesions, fenestration and biopsy of cystic lesions and excision of intra-ventricular masses. Between July 2012 and October 2013, in Nemazee Hospital, Shiraz, a descriptive study on a series of patients with intracranial lesions and hydrocephalus was established. Transventricular endoscopies were performed by a single team to fenestrate, biopsy or excision of cystic lesions as a primary treatment or as a first stage operation to facilitate the second microsurgical resection. This study was carried out with 35 patients by the mean age of 17 year-old (Range from 6 months to 70 years) including 19 females and 16 males. Some of most important cases were as below: Six cases of craniopharyngioma with large intraventricular cystic component and hydrocephalus had endoscopic cyst fenestration and septum plucidotomy as a first stage operation that followed with sub frontal approach in 4 patients. Combination of endoscopic surgery with microsurgical partial tumor resection and decompression made the second surgery easier with minimal post-operative complications. Five patients with solid-cystic optic pathway glioma had cyst fenestration and biopsy followed by chemoradiotherapy without any operation related complications. We found our policy useful in management of ventricular and paraventricular lesions with hydrocephalus especially in decision making for suprasellar solid-cystic masses.

Endoscopic fenestration of suprasellar arachnoid cysts has become a popular way in their treatment. Here, we describe our experience and results about this concept in Shiraz. This is a descriptive study on a series of patients with symptomatic suprasellar arachnoid cyst that had endoscopic ventriculocystocisternostomy by a single team in Shiraz between September 2008 and May 2013.All of them had at least 6 month post operative follow up with clinical and imaging assessments. There were 8 patients by the mean age of 8 years (Ranged 14 months to 24 years) including 3 females and 5 males. We had no operation related complications in our patients. Symptoms of high intracranial pressure were regressed in all patients including bulged fontanel, nausea and vomiting, etc. Four of them had ataxia in preoperative examination that was improved in two. One patient had complain of increase in headache intensity with no sign of high intracranial pressure and good imaging improvement. Seven patients had imaging improvement including regression of cyst size and hydrocephalus. One patient had concomitant C1- C2 instability due to kelippel- feil syndrome that was dismissed first. He came back with spastic quadriparesis 2 months after endoscopic operation and initial improvement of symptoms. He underwent C1-C2 fixation. Endoscopic ventriculocystocisternostomy is a useful treatment for suprasellar arachnoid cysts with low operation related complications and good clinical and imaging results.

Continuous intracranial pressure (ICP) monitoring is now an accepted part of neurosurgical practice, but in Iran, where has a high rate of the road traffic accidents, ICP monitoring does not use routinely. We are reporting the primary results of applying ICP monitoring in the patients with traumatic head injury in Bahonar Hospital in 2011. During one year, all patients with traumatic head injury who underwent ICP monitoring because of traumatic brain injury were evaluated considering the primary neurological status and the treatments they had received based on their ICP. We also evaluated the outcome 6 months after the injury. During this time, 18 patients underwent ICP monitoring. The mean age was 33±9.6 years and the mean GCS was 6±1.3. ICP monitoring showed high ICP in 13 out of 18 patients. Seven patients received barbiturate coma and 8 operations were performed on 6 patients with refractory high ICP. ICP was controlled in 10 patients. All three patients with uncontrollable ICP died during hospital admission. Outcome was related to the primary GCS, controllable ICP, and the pupil reaction. It seems that ICP monitoring is a safe and effective modality in the patients with traumatic brain injury. However it is necessary to conduct studies with large samples number to evaluate the role of ICP monitoring on long term outcome and functional recovery of the patients with traumatic brain injury.

Intracranial aneurysms are among the most common vascular malformations of the brain being associated with high morbidity and mortality. The epidemiology and clinical pattern of the disease will assist the physicians to encounter the disease more precautiously. The pattern and characteristics of intracranial aneurysms has not been previously described in Iranian population. Thus the aim of the current study is to determine the characteristics of the disease in an Iranian population. This was a retrospective cross-sectional study being performed in Al-Zahra and Kashani healthcare centers affiliated with Isfahan University of Medical Sciences during a 10-year period from 2003 to 2013. We included all the patients who presented to our centers with acute subarachnoid hemorrhage and were further diagnosed to have intracranial aneurysms. The patients’ medical charts were reviewed for demographic information, risk factors, the treatment options and the patients’ outcome. Overall we included 447 patients with mean age of 48.1 ± 14.1 (range 13 to 82) years out of whom 210 (47%) were men and 237 (53%) were women. Among the patients, there were 31 (6.9%) Armenian. Spring with 141 (31.5%) patients was the most common season of presentation. Family history of vascular anomalies was reported in 26 (5.9%) patients. Of the patients, 143 (32%) had more than one aneurysms. After the city of Isfahan, the most common place of residence was western parts of the province. World Federation of Neurosurgeons Scale (WFNS) was calculated to be 1 in 169 (37.8%) and 2 in 131 (29.3%) patients. The most common site of the aneurysms was middle cerebral artery in 166 (37.1%) followed by anterior communicating artery in 96 (21.5%). Saccular aneurysms were found to be the most common type of the aneurysm with a frequency of 296 (66.2%). Overall, 412 (92.2%) patients underwent surgical clipping while 37 (8.9%) were expired during the hospital stay. 35 (7.8%) patients died before operation. Infarction was the most common complication of the surgery being reported in 54 (13.1%) followed by neurological deficit in 24 (5.8%). Hypertension was the most common risk factor being recorded in 93 (20.8%). During the hospital stay, 46 (10.3%) developed vasospasm and 22 (4.9%) rebleeding. The clinical pattern as well as outcome of the patients with intracranial aneurysms in Iran is similar to that being previously reported in the international literature. As the mortality rates of these aneurysms is extremely high, screening work-ups especially in those with family history of vascular anomalies is recommended. Keywords:

Severe traumatic brain injury (TBI) has a major role in mortality rate among the other types of trauma. Progesterone’s neuroprotective effect has been confirmed on animals, although there are a number of animal models of TBI using progesterone for head injury, the effects of progesterone on neurologic outcome of acute TBI human patients remain unclear. The aim of the present clinical study was to assess the longer-term efficacy of progesterone on the improvement in neurologic outcome of patients with acute severe TBI. In this study we examined the pharmacotherapy effect of progesterone in patients suffering from traumatic brain injury with DAI and GCS ≤ 8 diagnoses. A total of 76 patients who arrived within 8 hours of injury with a Glasgow Coma Score ≤ 8 were enrolled in the study. Of 76 patients randomized, 38 received progesterone (1mg/kg per 12 hour for 5 days) and 38 didn''t. The primary endpoint was the Glasgow Outcome Scale score 3 months after brain injury. The mean GCS scores increased progressively in the two groups till the time of discharge, with no apparent differences among the treatment groups. There was a better recovery rate and GOS score for the patients who were given progesterone than for those in the control group at 3-month follow-up (50% vs. 21%) but this wasn''t significant from the point of statistical analysis (p = 0.08) however subgroup analysis showed a significant difference in the percentage of favorable outcome between the two groups with GCS of 5 to 8 (p = 0.03).But there was no significant difference, however, in dichotomized outcomes in the group with GCS of 3 to 5 (P > 0.05). The present study indicated that the use of progesterone may significantly improve neurologic outcome of patients suffering severe TBI up to 3 months after injury, especially those with 5-4; GCS<8, providing a potential benefit to the treatment of acute severe TBI patients. As there is no significant side effect of this drug, progesterone could be used in patients with severe TBI as a neuroprotective drug.

Every temporal process is in a serious need for formation of blood vessels. Neo-vascularization is induced by a variety of factors including vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and basic fibroblast growth factor (bFGF). Thyroid hormones also exert angiogenic properties in certain circumstances. We decided to measure the serum level of these factors in patients with glial cell tumors and meningiomas in a case-control study. This study was performed as a case-control study on patients referring to Shiraz Chamran Hospital during 2009-2010 with the diagnosis of either meningioma or glioma. All demographic and clinical data (including age, sex, date of admission and operation, symptoms, family and other pertinent histories, etc.) were also obtained and registered. The volume of the tumor and intraoperative bleeding were recorded. Blood was also drawn from every patient along with some healthy subjects (as controls) to measure the serum level of VEGF, PDGF, FGF and thyroid hormones. Data were analyzed using descriptive statistics, T-test and analysis of variance (one-way ANOVA). Ninety-six patients were enrolled in the study, 32 in each group. There was increased level of VEGF in patients with any cranial tumor, either glioma or meningioma. VEGF levels was highest among grade IV tumors, namely glioblastoma multiforme. VEGF was also higher in larger tumors. There was an increasing trend of serum VEGF levels as glioma grade increased. Highest VEGF levels were seen with parasagittal meningioma. In contrast to VEGF, PDGF was only slightly elevated in glial cell tumors, and it was significantly elevated in patients with meningiomata. Higher serum PDGF correlated with a higher amount of intraoperative bleeding, especially in meningiomas. Oligodendroglial tumors expressed higher PDGF levels in comparison to other glial tumos. No other significant relationship could be found for other factors, including FGF, and thyroid hormones. We could find an increased serum level of both VEGF and PDGF in CNS tumor patients. A differential role for PDGF was found in the pathogenesis of neovascularization for meningioma, and also for oligodendroglioma. No significant results could be found for FGF and thyroid hormones.

There are so many definitions about failed back surgery syndrome as persistent back and/or leg pain despite having completed spinal surgery. But when we proclaim that surgery is finished and how we know that something new doesn’t occur that by itself need special attention and treatment. In our center we observe many cases assume of failed back surgery syndrome to manage. We learnt that majority of this cases can be treated and getting good result with meticulous thorough work up to clarifying their undergoing pathophysiology. In this perspective there should be another definition for failed back surgery syndrome this definition should be only allocated to those patients that after full evaluation we cannot find any anatomopathologcal reason to explain their ailment scenario, in other words we have here a chronic pain syndrome case when we say FBSS. We seek an important goal by stressing in lexical debate on the term FBSS and the goal is to emphasize on planning an exhaustive evaluation of any patient with previous surgery on his or her back. Many of these patients has stenosis, recurrent herniated nucleus pulposus (HNP), pseudarthrosis, new instability, adjacent level disease and so many like that. All of this are surgically curable sufferings and we haven’t yet failed. After correcting those pathoanatomy we have small group of patients with really chronic pain disease that they also not failed back surgery cases they are the patients who need multimodal treatment option which exactly every pain specialist is thoroughly acquainted with. As lumbar surgery continues to grow in prevalence, so will the number patients suffering from FBSS. It is important for physicians treating this population to expand their knowledge of FBSS etiologies and appropriate diagnostic imaging modalities, combined with confirmatory diagnostic injections, and proper technique for interventional pain procedures. Therefore we propose to substitute the term FBSS with previously operated back syndrome which in addition to expunge the negative meaning of failure for the surgeon and patients it denote the different clinical situation of this patients which need special evaluation and treatment algorhythm.

The aim of this study was to determine predictive factors of blood transfusion and the length of hospital stay in patients who underwent spinal surgery that required discectomy or decompression with laminectomy, without segmental instrumentation. The purpose of this multi-center, prospective cross-sectional survey study was to determine predictive factors of blood transfusion and the length of hospital stay in 252 adults’ patients who underwent spinal surgery that required discectomy or decompression with laminectomy, without segmental instrumentation. Descriptive analysis, univariate and multivariate analysis were used to describe the predictive factors of blood transfusion requirement and the length of hospital stay (LOS). According to our statistical analysis the length of operation (R2: 0.65 and p< 0.001) and the volume of intra-operative blood loss (R2: 0.66 and p=0.033) significantly predict the postoperative LOS in patients who had had the lumbar discectomy. Additionally major predictors for intra-operative blood loss were the length of operation (R2:0.30 and p<0.001) and much more comorbid conditions (R2:0.34 and p=0.002).The considerable predictors for postoperative LOS in patients who had had laminectomy without instrumentation were the length of the operation (R2: 0.34 and p<0.001), perioperative blood loss (R2: 0.44 and p=0.042) and also age >50 (R2: 0.42 and p<0.001). As well, the length of operation (R2: 0.27 and p<0.001), mean of perioperative systolic blood pressure (R2: 0.31 and p<0.001) and the co-morbidities (R2: 0.42 and p<0.001) were the significant predictors for perioperative blood loss. In order to our study, in discectomy and laminectomy without instrumentation, length of operation and the volume of perioperative blood loss seem to be the significant predictors for length of hospital stay.

Posterior fossa non-tumoral cystic lesions include Dandy-Walker syndrome, Cerebellar hypoplasia, isolated forth ventricle, Mega cisterna magna and arachnoid cysts. The aim of this study is to evaluate the posterior fossa non-tumoral cyctic lesions in pediatics and to determine the available surgical techniques (their indications, methods, success rate and complication). This is a review article concentrating on the avaliable literature on posterior fossa non-tumoral cystic lesions tumors. The most important findings of the current literature indicates that ventriculo-peritoneal shunt insertion is the best treatment for Dandy-Walker syndrome. Microsurgical resection is the treatment of choice for isolated forth ventricle. Less invasive methods include neuro-endoscopy, aqueductoplasty and intraventricular ventriculostomy has also been shown to be associated with acceptable outcome and long-term results. Posterior fossa arachnoid cycts could be effectively treated by posterior microscopic surgical methods. Endoscopic cyst fenestration is a less invasive method for treatment of posterior fossa arachnoid cycts

Since the Monro-Kelline doctorine has been complied in 1783 and explaining the skull parts and their relations, medical sciences has been tried to keep this relation and improve the brain blood circulation in pathological status. Introducing ICP monitoring by Key and Rotzing in 1875 and the ability to register the waves in 1886 by Knoll give the physicians a new outlook to treat the patients. Since then there have been many efforts to decrease the intracranial pressure in pathological conditions to get the normal level. One of the effective methods is hyperosmolar therapy in neurosurgeries to reduce the increased intracranial pressure. In this way using the saline solution 30% was began from 1919 by Weed and Mckibben which has been changed continuously curing the recent century using other hyperosmolar solutions (Urea, Glycerol and Sorbitol). In 1960s monnitol appearance was a big turning point (Knapp 2005) that replaced the others. During two previous decades different concentrations of saline solutions has been again considered and widely used. Comparing the basic clinical characteristics of hypertonic saline with monnitol make it more popular (Ogden et al. 2005). On one hand monnitol application especially in brain trauma has been called into question (Wakai et al. 2007) and on the other hand it’s more efficacy in decreasing the intracranial pressure than monnitol (White et al. 2006; Ziai et al 2007). So with review of the recent studies on evaluation and comparison the monnitol with routine clinical concentrations of hypertonic saline, we can say that hypertonic saline is the better choice.

Epilepsy is the second most common neurological disorder. Seizure semiology is a simple allows localization of the symptomatogenic zone which either overlaps or is in close proximity of the epileptogenic zone. Clinical semiology can aids to precisely localize the epileptogenic zone is crucial for surgical success essential in cases of possible epilepsy surgery by Video–EEG monitoring. The clinical manifestation of a seizure (seizure semiology) is also of localizing value. For example, a typical patient with TLE may have an epigastric aura, followed by a quiet period of unresponsiveness with staring, lip-smacking (oral automatisms), picking at sheets or clothes (manual automatisms), contralateral dystonic posturing, postictal confusion and lethargy, and postictal nose wiping with the ipsilateral hand. If seizures arise from the dominant hemisphere, there is usually delayed recovery of language, often with transient aphasia and paraphasic errors on language testing. A typical frontal lobe seizure will occur from sleep with no warning, may show restlessness, prominent bilateral limb movements (such as bicycling or asymmetric tonic posturing, or both, and will end quickly with immediate recovery. This may recur several times in one night. Some patients with frontal lobe seizures may present with stereotypical bizarre and violent thrashing behaviors with prominent motor features. Occipital lobe seizures often have a visual aura, and may progress (due to electrical spread) into a temporal lobe or frontal lobe type of seizure. Parietal lobe seizures are the least common, may have a sensory aura, and tend to mimic frontal lobe seizures.

Most of the deformities caused or are in association with neurosurgical diseases. Many of them also cause neurological problems that needs neurosurgical operations. Many spinal intracanal and cord lesions and anomalies are seen in scoliosis and kyphosis such as cord tetherings, diastematomyelia, arnold–charri malformation, syringomyelia, diplomyelia, lipoma of cord. Different kinds of spine and spinal cord tumors, hydro-syringomyelias, inclusion tumors, meningoceles and meningo-myeloceles, and different types of occult spinal dysraphysms, cystic lesions such as neurentric or ependymal cysts, hydatid cyst, lumbo-sacral cystic lesions like lepto-meningeal cysts and anterior sacral meningoceles and many other pathologies that are operated by neurosurgeons. Many of deformities needs decompression by neurosurgeon. Some of deformities occur after neurosurgical procedures that is better to manage by neurosurgeon. In neurofibromatosis variety of scoliosis for example there are many neurosurgical problems like different CNS tumors, dural ectasia and cord compression that needs neurosurgical interventions and etc. so at least such deformities should managed by neurosurgeons that are expert in deformity surgery.

Treatments of intractable epilepsy by neurosurgical operations have been prevailed in Iran. The success rate completely depends to precise comprehensive evaluations. The purposes of Comprehensive Epilepsy Program (CEP) are to delineate the source of epilepsy, to describe current burden of attacks, and to suggest outcome of surgery. The pre-operative assessment includes video EEG monitoring, structural and functional neuroimaging and neuropsychological evaluation. The likelihood of the success of surgery is increased when all test results point to a single epileptogenic focus. The cognitive and behavioral evaluations include standard neuropsychological assessment and intracarotid anesthetic testing (Wada). The role of neuropsychology is its potential to predict lateralization and perhaps localization of a brain pathology based on deficits in cognitive function. Neuropsychological assessments can also demonstrate cognitive dysfunction in conditions that structural brain lesion is not detected. The Wada test has been used to determine the cerebral speech dominance and to predict postsurgical amnesia after temporal lobectomy.

Pluripotent stem cells, which are capable of differentiating in various species of cells, are hoped to be donor cells in transplantation in regenerative medicine. Embryonic stem (ES) cells and induced pluripotent stem cells have the potential to differentiate in approximately all species of cells. However, the proliferating ability of these cells is high and the cancer formation ability is also recognized. In addition, ethical problems exist in using ES cells. Somatic stem cells with the ability to differentiate in various species of cells have been used as donor cells for neuronal diseases, such as amyotrophic lateral sclerosis, spinal cord injury, Alzheimer disease, cerebral infarction and congenital neuronal diseases. Human mesenchymal stem cells derived from bone marrow, adipose tissue, dermal tissue, umbilical cord blood and placenta are usually used for intractable neuronal diseases as somatic stem cells, while neural progenitor/stem cells and retinal progenitor/stem cells are used for a few congenital neuronal diseases and retinal degenerative disease, respectively. However, non-treated somatic stem cells seldom differentiate to neural cells in recipient neural tissue. Therefore, the contribution to neuronal regeneration using non-treated somatic stem cells has been poor and various differential trials, such as the addition of neurotrophic factors, gene transfer, peptide transfer for neuronal differentiation of somatic stem cells, have been performed. Here, the recent progress of regenerative therapies using various somatic stem cells is described.

To report a case of diffuse intracranial calcification in hyperparathyroidism due to metastatic infiltration of parathyroid gland. We report a 53 year-old man that his significant clinical presentation was seizure, and resting tremor. and after investigations hyperparathyroidism confirmed basis on his laboratory data. He had decreased PTH & calcium & increased phosphorus. and ultimately the diagnosis of hyperparathyroidism due to metastatic infiltration stabilized. The source of his metastases was colorectal adenocarcinoma. his brain CT images revealed diffuse intracranial calcification in basal ganglia and subcortical white matter and cerebellum intracranial calcification is a common finding in clinical practice but diffuse intracranial calcification is a rare finding. Hypoparathyroidism is well known to cause basal ganglia calcification in most of the patients. But diffuse intracranial calcification caused by hyperparathyroidism is rare.

High-intensity focused ultrasound (HIFU) provides focal delivery of mechanical energy deep into the body. This energy can be used to elevate the tissue temperature to such a degree that ablation is achieved. HIFU under magnetic resonance imaging (MRI) guidance (MR-HIFU) is a completely non-invasive technology for accurate thermal ablation of a target tissue while neighboring tissues and organs are preserved. The combination of HIFU with MRI for planning, real-time monitoring and outcome assessment of treatment markedly enhances the safety of the procedure. Recent technological developments open the field of therapeutic application to the brain through the intact cranium and is a noninvasive treatment strategy for various brain diseases. Promising results of recent studies have been shown for the treatment of adenomyosis, malignant tumors of the prostate, breast and liver and for various intracranial applications, such as thermal ablation of brain tumors, functional neurosurgery and transient disruption of the blood-brain barrier. This review examines the physical principle and rapid development of MRI-guided HIFU (MRI and HIFU) methods over the past few years and discuss their future potential in neurosurgery.

Neurosurgery deals with diseases of the central nervous system. Surgery of brain is very difficult, since extremely localized operations are necessary due to the complicated structure and fragility of the brain. The application of lasers in neurosurgery has been extremely slow compared with other medical fields. This was mainly due to two reasons. First, the ruby laser was not of great help in neurosurgery. Second, initial experiments with the CO2 laser were performed at too high energy levels. It then took some time interest in neurosurgical lasers, especially moderate CO2 lasers and Nd: YAG lasers. The principal advantages of lasers in neurosurgery are evident. Lasers are able to cut, vaporize, and coagulate tissue without mechanical contact. This is of great significance when dealing with very sensitive tissues. Simultaneous coagulation of blood vessels eliminates dangerous hemorrhages which are extremely life-threatening when occurring inside the brain. Moreover, the area of operation is sterilized as lasing takes place, thereby reducing the probability of potential infections. Because Surgery of brain is very sensitive and lasers have interest application in neurosurgery, so the aim of this study was evaluate the recent and important application of some type of laser such as CO2, Nd: YAG, Holmium, Argon and etc in neurosurgery.

AEDs are frequently prescribed to control postoperative seizures after nero-surgery. The aim of this study was to provide a review related to evidence-based-pharmacotherapy after neurosurgery. A total of 300 research papers were selected in order to achieve a provision for this study at the Isfahan Kashani Neurosurgery ward as a pioneer center in Isfahan/Iran. The great percentage of patients was getting antiepileptic management since neurosurgical procedure, mainly as monotherapy, with a reasonable amount of conservative and newer AEDs. Supervision after a neurosurgical process is an extensively argued subject, as evidence is rather incomplete, particularly for the newer AEDs. Early seizures signify a well-recognized hazard feature for postsurgical epilepsy, as they associate with the rigorousness of the cerebral maltreatment. There are numerous drug-drug interactions with both older and newer AEDs. According to recent publication newer AEDs such as levetiracetam and zonisamide have a tendency toward less seizure attack and an enhanced acceptability than traditional AEDs, although disparities were not statistically considerable. Adverse events increased more often, subsequent to phenytion prescription as first line monotherapy plan. Treatment using chemo-radiotherapy and steroids are common in a high percentage of patients after neuro-surgery. Therefore prescription of AEDs such as carbamazepine, phenytion and phenobarbital could increase the clearance (CL) of corticosteroids and anticancer agents. Administration of older AEDs after neuro-surgery might affects pharmacokinetics parameters such as: 1) a decrease in bioavailability of other drugs (F↓) due to potent induction or inhibition of CYP450 related to metabolic events and 2) a decrease in clinical efficacy (CE↓) that unfortunately could results to therapeutic failure after neurosurgeon.

Pain is The 5th Vital Sign, by Journalist and writer: Marni Jackson (Book-June2002) Although Pain is the most common symptom that leads the patient to doctors (Nilges Traue 2007) but Pain is not the problem but chronicity. A. Nachemson, 1998. Definition of chronicity is not only duration of pain and in the other hand the chronic pain differs from chronic pain syndrome. Chronic pain is the pain which persists for 3, 6 or more months after the initial lesions. For example a patient with trigeminal neuralgia has several years'' facial pain and he improves after MVD. Chronic pain syndromes are a relatively new concept in our understanding of pain. That are rarely recognized or diagnosed as a separate clinical entity among healthcare professionals. In 1936 SAUERBRUCH, WENKE wrote…to discover the singularity of the pain disease “Algo patients”, on which the pain is obviously not a symptom besides others but on which the pain is the real disease - without any unknown physical cause. The character and importance of pain written by FERDINAND SAUERBRUCH and HANS WENKE 1961) chronic pain as a disease? When acute pain becomes chronic pain? And when pain disease?) Functional somatic symptoms are presented with pain, disability, suffering and less organic interference. Clear vision of patients about «their» disease in contrary to the lack of scientific and somatic explanations. (Mohadjer 2012). Chronic pain syndromes (pain disease) must be considered as a psychologic-physiologic disability. The understanding and treatment of pain disease comprises a new medical disease model; however, some of the original symptoms are considered to have an underlying organic pathology. Recognition of the need for differentiation between the various forms of pain is paramount to the success of the treatment process. Such evaluation is necessarily interdisciplinary. An early complete history and physical examination are the basis from which the physician draws logical conclusions about the patient to prevent progression. The long-range solution lies in a dynamically structured, progressive physical and mental reactivation program implemented by a highly trained interdisciplinary team of professionals using a holistic approach.

To develop a strategy to determine a sound method for decision making in lumbar spinal canal stenosis (LSCS), based on postoperative patient satisfaction. A sample of patients with LSCS was studied to indicate those who underwent surgery and those who received conservative treatment. The SSS, the NCOS, and the ODI tools were recorded. Satisfaction of patients who underwent surgery or conservative was evaluated prospectively using the satisfaction Index presented by Stucki et al. Then, all case records were assessed for morphology grade and dural sac cross-sectional surface area (DSCA) on MRI in order to indicate who benefited from surgery or conservative and who did not. The mean age of 357 patients was 57.5 (10.9) years. Of these 176 patients underwent surgery. Post-treatment satisfaction was found for surgical group patients (93.2%) and conservative group patients (84.5%) at last follow-up. Most patients (86.4%) who underwent surgery identified as having grade C and grade D while those who received conservative treatment were identified as having grade A and grade B (P < 0.01). Overall satisfaction with surgery was found to be higher among patients with Grade D stenosis (95%). Satisfaction by cross-sectional surface area did not show a consistent pattern. However, those with cross-sectional surface area less than 100 mm2 benefited more from surgery. According to the findings a decision matrix was proposed. The findings suggest that the morphology grade and the DSCA jointly are useful parameters for helping clinicians to make decision in order to manage LSCS patients.

To identify indications for 125Iodine brachytherapy in brain tumor and determine whether the outcomes are comparable with the other treatment. MEDLINE, EMBase, CINAHL and PEDro in English were investigated to October 2013. From the identified literature, brain tumors used to treat with 125Iodine brachytherapy were collected and classified. Complications and survival of cases were extracted and categorized. We have reviewed 201 published articles and studied indications for 125Iodine brachytherapy in brain. 125 Iodine have been successfully used in astrocytomas I-III, GBM, metastases and several other tumors particularly in an eloquent areas and comparable with other treatment methods. Preferably, the diameter of the tumor should be >4 cm. The 125Iodine Brachytherapy with careful selection of cases, with circumscribed and relatively small sized tumors appears to be a safe, feasible and minimally- invasive treatment. In case of larger tumor volumes (>4 cm), partial resection combined with brachytherapy is recommended.

There are a number of ethical issues which confront medical practitioners in their profession many of these are common to all physicians and are well known. They include areas like confidentiality, informed consent, relationship with colleagues, advertisements, media publicity, professional charges, commissions, issuing of medical certificates and many others. A few situations which are especially relevant to neurosurgical practice and which often confront the clinician in day to day management of cases will be presented in this paper. For example management of a child with meningomyelocele and paraplegia, continuing aggressive treatment of a patient in brain death or vegetative state condition and etc.

We report a case of paraplegia following epidural anesthesia in a male patient who was scheduled to undergo rectal carcinectomy. An epidural catheter was uneventfully inserted at L1-2 interspace before general anesthesia. The patient complained numbness and weakness in lower extremities, and paraplegia was developed with decreased pain and tactile sensation below T10 level at 72 hours postoperatively. MRI demonstrated metastatic spinal tumor at T8-9 level with spinal cord compression. This case suggested that the preexisting spinal pathologies must be considered in determining the causes of severe neurologic complications after central neuraxial block, and MRI should be employed without delay.

Thalassemia intermedia is mild form of thalassemia that usually present later in life and transfusion is occasionally needed in these patients. Erythropoiesis is increased in thalassemia causing erythroid marrow hyperplasia as well as EMH which is a common compensatory mechanism for chronic anemia found in such patients. EMH usually occures in liver, spleen, kidneys and as paravertebral region. It is observed in 30%–60% of patients with thalassemia intermedia while involvement of the paraspinal region has a prevelance of about 11%–15% among these cases. A 26 year old man with beta thalassemia intermedia developed pain in low back region with progressive paresthesia because of multifocal EMH which occurred all around the spinal canal with compression over the cord. This case was a recurrent one who had a previous episode of disease 6 years ago. The patient could be managed with repeated episodes of radiation to the spine and all the lesions disappeared in the last follow up. Reporting this unique case and its characteristics, different aspects of a better treatment protocol in similar cases will be discussed. Management of recurrent neurological deficit due to EMH compressing the spinal cord has not been discussed in the literature previously.

Neurofibromatosis type 1, or Von Recklinghausen disease, is the most common of the neurocutaneous syndromes, occurring in approximately 1 in 3000 people. Cutaneous, Systemic and Neurological features are the main items that the patients suffering from them. Their management is palliative, either cosmetic or function preservation. We present a 3.5 years old female with unilateral cranio-orbito-facial enlarging and infiltrating mass, involving forehead, orbit and its contents. There is also right Hemicraniocerebral Hypertrophy and right sided large single ventricle. She had no neurologic deficit, except inability to open right eye (mass infiltration). She underwent right orbital roof decompression for the management of right exophthalmous, at the 6 month of age, as the earliest presentation of the patient. We have done right sided orbital excentration, further advancement of orbital rim and reconstructive cranioplasty in accompany with right occuloplastic orbital prosthesis. In NF-1, the definite diagnosis is by finding of Lisch Nodule, which is age dependent, but the management is palliative and controversial. Right orbital roof decompression as the management of early exophthalmous (at 6 month of age), seems to be inappropriate. Are reconstructive Palliative and cosmetic surgery (above mentioned ones) appropriate, sufficient and efficacious? What should we do about Hemicraniocerebral Hypertrophy and ventriculomegaly?

Primary tumors arising in the brachial plexus are rare. Presenting signs and symptoms included: mass, paresthesia/numbness, radiating pain, local pain, and weakness. The duration of symptoms ranged from 2 months to 10 years prior to treatment, according to literature. They are include schwanomma, neurofibroma, malignant peripheral never sheet tumor (MPNST), and desmoid tumor. Some of neurofibromas are associated with von Recklinghausen''s disease (VRD). In this case a 31 years old lady with history of 2 months of supraclavicular mass and left arm paresthesia present. On examination only a large mass palpated but motor force of upper limb was normal. She underwent fine needle biopsy in another center with pathologic diagnosis of neurofibroma, and referred to our center. In brachial plexus MRI a large well defined tumor of neural plexus was seen. She operated through supraclavicular approach (with alertness to infra-clavicular approach if needed), and tumor totally resected by microscopic dissection. Pathologic diagnosis was neurofibroma. After surgery she was neurologically intact and improved her paresthesia gradually. On follow up MRI no tumor remnant or recurrence occurred and she is well clinically. Primary tumors arising in the brachial plexus are rare. Careful workup, surgical technique, and attention to pathological diagnosis optimize managemen.

Oculorrhea, or cerebrospinal fluid (CSF) leakage through a cranio-orbital fistula, is a rare complication of traumatic injury which management remains elusive. We herein report a 33-year-old man with traumatic brain injury following a car to car accident who developed oculorrhea. Brain CT scan revealed a depressed skull fracture in frontal bone under a laceration in his forehead with left orbital rim fracture and skull base fracture within frontal sinuses and left frontal contusion with pnemocephalus. He underwent surgery to remove contaminated bony fragments and secondary repair of dural laceration beneath the fracture. His frontal sinuses were also exenterated with abdominal fat to prevent CSF leakage. Unfortunately the patient developed CSF leakage from his eyes (oculorrhea) 2 days after the surgery; so a lumbar drain was inserted for him and his CSF leakage was stopped. After 4 days the lumbar drain was clamped for 24-hours and the patient did not develop CSF leakage anymore. Oculorrhea is a rare type of CSF leakage following skull base fractures. If it is not complicated with meningitis, effective lumbar drainage will be the non-surgical treatment of choice for its management.

to report a case of posterior intersegmental fusion of unstable Jefferson fracture. The patient is a 37-year-old man with neck pain that was the victim of a motor vehicle accident. His neurological examination was normal. A cervical computed tomographic scan revealed an isolated unstable Jefferson fracture associated with Spence criteria.The patient was treated via C1 lateral mass screws construct. The screws were connected with a rod and nuts to reduce lateral spread of the lateral masses. The postoperative CT showed that C1 lateral mass screws were well positioned. The treatment of unstable Jefferson fractures remains controversial. Conservative treatment usually associated with the longtime of immobilization in halo vest, whereas surgical treatment generally eliminating the range of motion of upper cervical spine. It seem that the ideal treatment of unstable Jefferson fractures is expected to preserve the function of C0-C1-C2.

Surgical approach for clival tumor is an invasive treatment that associated with significant rate of morbidity and mortality. We describe transnasal endoscopic approach for treatment of clival chordoma. the patient is a 37 years old man that suffered from headache, diplopia, dysphagia and dysphonia. MRI revealed huge clival mass lesion (isointense in T1 and T2) that compress brainstem. On contrast-enhanced MRI enhancement was shown. A neuronavigational image-guided endoscopic transnasal-sphenoidal approach was performed to total resection of the tumor. After surgery pathological diagnosis was made as chordoma. After one week the patient discharge with good condition and no more neurological deficit was observed. endoscopic transnasal trans-sphenoidal approach is an excellent choice for resection of clival mass particular which are located medially. With advancement of instrument this approach will be treatment of choice for many of these tumors.

Akinetic mutism is a behavioral state wherein a patient seems to be awake but does not move or speak. We present a patient who developed akinetic mutism after total resection of huge parasagital meningioma The patient is a 35 years old woman that referred to our hospital with a history of headache for 2 years ago. Neurological examinations were normal. MRI show a huge parasagittal mass lesion with shift of the midline and peripheral edema. Brain MRV showed occlusion of superior sagittal sinus with the mass. The patient underwent surgery with diagnosis of parasagittal meningioma. The tumor was resected totally (sympson’s classification grade 1) and the superior sagittal sinus was ligated between the middle segment and posterior segment. After surgery the she extubed and referred to ICU. she remained aware, mute and motionless. The CT SCAN showed peunomocephaly. 2 week after surgery she was speaking one-syllabe word and three week after surgery she was speaking normally and has quadriparesia. After 2 month of surgery she recovered her motor function fully. Akinetic mutism is an infrequent complication that can occur after brain surgery although this condition usually is transient.

Epidermoid cyst are benign tumors from ectoderm remnants. Intramedullary epidermoid cysts are uncommon. We present a 33 years old woman that was evaluated for acute low back pain and right leg radiculopathy. On examination she had right leg weakness and spastic gait. Lumbosacral MRI showed l5-s1 disc herniation that not justified all signs of the patients. The patients underwent thoracic MRI that showed an intramedullary lesion in the dorsal cord at T3-T4 level that had a pearly white appearance on exploration. Histologic examination demonstrated epidermoid cyst. Epidermoid cyst can be considered in differential diagnosis of intramedullary tumors. Their removal leads to recovery.

Since this entity has not been described previously we have tried to describe its overall clinical and radiological features. It is s a case series including 19 cases with up to10 years follow-up.

Intracerebral aneurysm formation due to infective process is a known entity; but brucella-related aneurysm has rarely been reported. A 34-year-old male who presented by fever and two times attack of intracerebral hemorrhage due to multiple distal Middle cerebral artery aneurysm, was managed surgically because of no improvement on angiography by trial of antibiotic therapy. At secondary work ups, systemic and CNS brucellosis was diagnosed and proper antibiotic regimen was administered, so full recovery could be achieved. By a thorough review of the literature, all the previously reported cases and any possibility of treatment is been reviewed.

Primary melanocytic neoplasms of the central nervous system (CNS) are rare lesions arising from melanocytes of the leptomeninges. These leptomeningeal melanocytes are found at highest density underneath the brain stem and along the upper cervical spinal cord. Thus, most reported cases of meningeal melanocytomas are located in the posterior fossa and the spinal cord, and presentation of the tumor in supratentorial is very rare. A 19-year-old man presented with headache and seizure at our department. Neurological exams were otherwise normal. A left temporal space-occupying lesion was seen on magnetic resonance imaging. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images. On contrast-enhanced MR enhancement was shown. Prior to surgery, meningioma was diagnosed and gross tumor removal was performed. After surgery pathological diagnosis was made as meningeal melanocytoma WHO grade 1, the patient received radiation therapy. No tumor was seen on follow-up MR images one year after surgery. presentation of melanocytic meningioma in supratentorial is very rare. Although this lesion is benign, but may behave aggressively. For most cases complete surgical resection of the lesion is curative. To prevent relapse of the tumor radiation therapy is important, especially in cases of incomplete surgical resection.

Although the vertebral artery injuries (VAI) associated with cervical spine trauma are usually clinically occult, they may cause fatal ischemic damage to the brain stem and cerebellum. The patient is a 76 years old man that reffered to our hospital with falling tree (about 5 meter). On arrival at the Emergency Department the patients vital signs were all within normal physiological parameters. GCS was 15/15. He had suffered from neck pain and headache and vertigo. In physical examination he had upper cervical spine tenderness but there was no abnormal palpable deformity. Other physical examination was normal. Brain CT scan was normal.in cervical spine x-ray there was no abnormality.The patient was underwent to cervical spine ct scan C-spine CT demonstrated posrterior arch of atlas extended to foramen transversariom and transvers process. CT-angio demonstrated right vertebral artery dissection. The patient was underwent to treat by UFW heparin and warfarin. Blunt vertebral arterial injuries are more common than previously reported. Screening patients based on injury mechanisms and patterns will diagnose asymptomatic injuries, allowing the institution of therapy before stroke. Systemic anticoagulation appears to be effective therapy.

Congenital absence of the posterior elements of vertebra in lumbar spine is rare. Our review of the literature revealed only some reported cases of incomplete congenital absence of the posterior elements. There are some documents that reported the congenital absence of the lumbosacral articular facet joint. Complete congenital absence of the lumbar posterior element has been quite rarely reported in the literature. In this case we reported rare a case with congenital absence of the posterior element of lumbar vertebra including facet joint, lamina and spinous process and transverse process that produced back pain and did not respond to conservative treatment and continued to a more chronic illness. Because the patient did not respond to conservative management, there was an indication for surgery which include posterior spinal fixation with autograft fusion.

Intracranial infections following neurosurgery are most commonly caused by bacteria. Postoperative herpes simplex encephalitis has been described but rare. Herpes simplex virus (HSV) encephalitis is a life-threatening consequence of HSV infection of the central nervous system. Although HSV encephalitis is rare, mortality rates reach 70 per cent in the absence of therapy and only a minority of individuals return to normal function. Antiviral therapy is most effective when started early. In our case report, impairment of consciousness and hypertone of arms and legs complicated the post-operative course in a patient who underwent surgical removal of a meningioma. Brain magnetic resonance imaging (MRI) and computed tomography scans performed after onset of symptoms of infection suggested HSV encephalitis, and polymerase chain reaction identification of HSV 1 DNA confirmed the diagnosis.

Desmoid tumors, a rare type of soft tissue neoplasm (new abnormal growth or tumor), usually develop in the arms, legs, abdomen or chest of children and adults. Sometimes they are called aggressive fibromatosis. Although they typically don''t spread to other parts of the body, they can quickly invade nearby tissues and organs.in this case report we represent a rare case which underwent surgery for posterior fossa hemangioblastoma 3 years ago and came back with cervical tumor with extension to posterior fossa and pathology report compatible with fibromatosis (desmoid

We present a patient with symptomatic cavum septum pellucidum that underwent neuroendoscopic fenestration. The patients, is a 27 -year-old woman, that presented with severe headache neurological exam was normal. Imaging studies demonstrated large septum pellucidum cysts without hydrocephaly. The patients underwent endoscopic transventricular cyst fenestration with rigid endoscope Postoperativelythe patient symptoms resolved immediately. Cavum septi pellucidi is present in approximately 15 % of adult brains that rarely enlarge and become symptomatic as a result of obstruction of the interventricular foramina, distortion of the vascular structures of the deep venous system. neuroendoscopic fenestration is considere for treatment of CSP. This is a safe and microinvasive approach that can lead to complete resolution of clinical symptoms.

We present a case of scalp arteriovenous malformation. A 27-year-old man with a soft mass on his Rt. retroauricular region from few years ago presented with a 10*6 cm pulsatile, soft, compressible mass posterior to the ear. There is bruit over the mass, and powerful pulsation in occipital and superficial temporal arteries of the Rt. side. CT scan revealed a Rt. parieto-occipital scalp mass with normal intracranial content. There is indentation over the outer table in parieto-occipital region. CT Angiography demonstrated normal intracranial blood vessels, very large tortuous tuft of vessels in Rt. parieto-occipital region with huge feeder from Rt. occipital artery and large one from Rt. superficial temporal artery, there is also a small feeder from Lt. side. Cerebral Angiography showed normal intracranial content, huge high flow vascular anomaly in Rt. parieto-occipital region with a very large feeder, most probably occipital artery, from Rt. external carotid artery. Surgical management and post-op studies of the patients are going to be presented. The AVM are rare tumor masses of the scalp for which surgical management should be considered.

Transsphenoidal surgery is considered to be a safe, relatively low risk procedure for the resection of pituitary lesions. Bilateral internal carotid artery thrombosis after transsphenoidal surgery is extremely uncommon with only few cases as per the author’s review of the literature. We describe a case of bilateral internal carotid artery thrombosis after transsphenoidal surgery for pituitary macroadenoma and review the literature on this rare entity. A 39-year-old man, who underwent transsphenoidal surgery for a pituitary macroadenoma. The presence of soft and suction able nature of the tumor permitted to total resection. Progressive loss of consciousness 18 hours after surgery occurred, an emergency CT scan showed no evidence of hemorrhage but stroke in domain of both internal carotid artery. Twenty hours later, MRA revealed arrest of arterial flow and thrombosis of intracvernosis portion of both internal carotid arteries resulting this extensive stroke. On the fifth postoperative day, the patient died as a result of this extensive stroke IT should be in our mind that this rare complication may occur in transsphenoidal pituitary surgery and is not avoidable, early diagnosis is important to try to prevent this serious complications.

Histiocytosis is relatively rare disease which may be focal or with multiorgan involvement and in many cases with unpredictable course. We report two cases of adolescent histiocytosis; one with multiorgan involvement and sellar region tumor and a case with isolated sellar and suparasellar histiocytosis and discuss challenges that must be overcome. Sellar histiocytosis is a challenge to manage and surgery may have a role to decompress optic apparatus and confirm diagnosis. Immunohistochemical study is very helpful to diagnose this type of tumor.

Acute cranial subdural hematoma (SDH) commonly occurs after traumatic brain injuries. Although, the vast majority of acute SDHs larger than 10 mm in thickness require immediate surgical evacuation, in rare occasions spontaneous resolution may occur. Two important mechanisms explained for this phenomenon are blood push out and blood wash out. In this article, we discuss two cases of spontaneous resolution of acute cranial SDH in addition to the proposed theories explaining this phenomenon. Furthermore, clinical parameters and imaging characteristics that might predict such phenomenon, are also reviewed. It is possible to consider conservative management with ICU case for such patients if clinical and paraclinical criteria supports this decision.

The coexistence of PA and another type of brain tumor is a very rare clinical scenario. The pathogenesis of coexistence of different lesions in the sella and suprasellar region has not been elucidated. Two cases of concomitant brain tumors are reported. Both tumors occurred in the sellar region. The literature is reviewed on this topic and the possible pathogenesis and management protocol of similar lesions are discussed. A 37-year-old lady presented with history of oligomenorrhea and headache. Imaging revealed tumor located within the sella and another dural based lesion lying over the planum sphenoidale. Another case a 42 year old man was referred to our department with the diagnosis of Acromegaly. Imaging revealed the intrasellar lesion and also a suprasellar lesion.in two cases a transsphenoidal adenomectomy and decompression of the optic apparatus was achieved using a right pterional craniotomy and vision improved remarkably. In our experience, it is suggested; a-using high quality imaging can preclude loosing golden time for preservation of vision in these CCBT, b- surgical approach should be tailored according to the individual patient''s symptom, the feasibility of resection all two tumor in one session for the attending surgeons experience. It is important to distinguish between an adenoma coexisting with a suprasellar meningioma because the treatment strategy for these tumors is different. The ideal approach for treatment of such concomitant tumors is not clear due to lack of adequate experience in the literature.